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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t Application is hereby made to the San Joaquin Locale Health District for a permit to construct and/or install the work herein described. This application is made incompliance with San Joaquin Co-nty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Qi t Job Address I /5, (0-- :L'11N City 111 Lot Size PM Owner's Name L C1 " `�� Address /�� "� ? ' - Phone Contractor t Address License No. __ _ Phone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O r- DESTRUCTION 171 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "DISPOSAL FLO. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [-I Domestic/Private 1-1 Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public CI Other Ll Delta Depth of Grout Seal + Type of Grout-_— I rout-I 1 Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Ll Well Diameter Sealing Material Stop 501 3 -� Depth Filler Material (Below-50') TYPE OF SEPTIC WORK: NEW INSTA LAT( EPAIR/ADDITION i l DESTRUCTION I I (No septic system permitted if public sewer is available within 206 feet.) t i Installation will serve: Residence Commercial— Other {n Number of living units: Number of bed oms Character of sot{to a depth of 3 feet:� Water table depth d� I SEPTIC TANK ❑ Type/Mfg', Capacity Cla - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal -e Distance to nearest: Well Foundation .Property.Line LEACHING LINE � No. & Length.of lines L 11 ? Tota! length/size A FILTER BED ❑ . Distance to nearest: Well x+50 •Foundation � Property Line - SEEPAGE PITS I I Depth Size _ Number �} SUMPS 0' Distance to nearest:'"""""'Well-"° '"' M—Foundation Property Line DISPOSAL PONDS ❑ $ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for ail required insp ctions. Complete drawing on reverse side. �(G Signed X — Title: Date: 7 by " 0 . R SPAR_TMENT USE ONLY J �` Application Accepted by Date e `Area •. � k b Data 7 Pit or Grout Inspection by Date Final Inspectiony _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,�CA 95201_, y r 'i ... . - .- _ ..- t - _. .. _ _ r IFEENFO MOUNT DUE' AMOUNT REMITTED„ w' CK RECEIVED BY DATE PERMIT'NO. . yr.EH 13-24(REV.�/n 51 `�04 c�7c EH 14-28