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y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 601 E. HAZEL 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 Heaith 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. Job Address '7�0� /iAs� !C� City 1O 1,._Lot Size/75w,K ZZrl PM Owner's Name b&C 14Address Phone y'3t- S3 Contractor s ddress License No. ] 042 T Phone 8—Z 303 TYPE OF WELL/PUMP: NEW W LL ;K WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP INSTALLATION SYSTEM REPAIR 171 OTHER F) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 W LlIndustrial ❑ Open Bottom C] Manteca Dia. of Well Excavation S It Dia. of Well Casing X Domestic/Private 1K Gravel Pack ❑ Tracy Type of Casing •V. C - Specifications t'1 Public (_1 Other ❑ Delta Depth of Grout Seat I CaD Type of Grout — I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by141 - c ' _ 4 Repair Work Done El Type of Pump _�f;,p-- H-P- State Work Done Well Destruction ❑ Welt Diameter Sealing Material Itop 501 ,Y, Jc Depth ` Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity- - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal {{{ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS l I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ > r `'t - "' ', — 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 l employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature i 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 applican st call for all requl rns ns. Complete drawing on reverse side. Signed X Title: Date: z R DEPARTMENT USE ONLY Application Accepted by Date �3 9-0Area Pit or Grout Inspection byft'� L- Date Final Inspection by_ Date,l(U, '�� // ti �� Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385a 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 CK H RECEIVED BY DATE PERMIT'NO. INFO,q ♦.EH13-241REV.tin51 Ta EH 14-211 _