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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) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f�� [ Job Address 4(6 "' /�l �C� — City Lot Size PM Owner's Name "' ll�Nf Address z Phone 77Z— fire Contractor � wry ttf 1 Address � 9� �� license No. Zs�¢34 7 Phone 'PPS ,4-,4V07 TYPE OF WELLefPUMP.: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �'*�PUMP INSTALLATION ❑ SYSTEM REPAIR El' OTHER ❑ DISTANCE,TO_NEAflES,T.:_5 DTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ik INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'xcavation r Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 Specifications ('l Public 1=1 Other ❑ Delta Depth of Grout'Seal Type of Grout _ I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ (Type of Pump F � H.P. State Work Done Well Destruction I]' Well Diameter 'Sealing Material Itop 50') V. S Depth ` Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSALLAT ON 11 REPAIR lADD1TION. DESTRUCTION'I•I (No septic system permitted if public sewer is I { available within 200 feet.► u Installation will serve: Residence— Commercial_ KOther Number of living units: Number of bedrooms Character of soil to a depth of 3 flet Y "'"""-""/'' / Water table depth SEPTIC TANK _� ❑. Type/Mfg/l�F�i/�ENl�/��d�i��i/ .C�apacity No. Compartments . t PKG. TREATMENT PLT. ❑ F __� �..w �- Method of Disposal Distance to nearest: Well Foundation Property Line L LEACHING LINE No. & Leng h•of lines �� Total length/size sD FILTER BED ❑ Distance to nearest: Wellt w;Foundation ��` Property Line SEEPAGE PITS 1 Depth Size 7' Number f SUMPS ❑ Distance to nearest: well �� Foundation rU r Property Line l�� 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, I 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 c or all re ired ' ctions. Complete drawing on reverse side. f Signed X._� Title: £'!rt'/�9y L r Date: ��,=AI�TIMI�ENT USE ONLY.. • - Application Accepted by Date Area I Pit or Grout Inspection by Date Final Inspection by Date�40 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �TE,INF 'CASH EH 13-241 REV.1 i k 51 EH 14-26 Or �� 3