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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA (� Telephone Q091 466-6781 PERMIT EXPIRES TYEAR 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. , '700 Job Address RM P—c_ __ _- City Lot Size SPM 1 I _ Owner's Name + � �= � Address 700 r<nq a> Phone Contractor i-t i Address _P )-U/'7q-. "7 . 7 License No.JLT? Z Phone es, 0 77 TYPE OF WELL/PUMP: KEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION jC SYSTEM REPAIR❑ OTHirR ❑ DISTANCE TO NEAREST: SEPTIC TANK 1i"QJ SEWEiiTINES DISPOSAL FED -,PROP.URE'7�tl� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ISO INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S t E) Industrial Ope6 Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing IV Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �ee7. I Specifications f"I Public ❑ Other ❑ Delta r Depth of Grout Seal, Type f Grout �q . _. I I Irrigation C;Z�..Approx. Depth l I Eastern YSurface Seal Installed by �-A , Repair Work Done ❑ Type of Pump :S,-A H.P. —State-Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Qb Depth Filler Material (Below 501 G TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION t I (No septic system permitted if.public-sewer is f _ available within 200 feet.l Installation will serve: Residence f Commercial_ Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: -=Water-table depth SEPTIC TANK ❑ Type/Mfgp Capacity No. Compartments PKG. TREATMENT PLT, ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Le-19-Th of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size F Number w, Q SUMPS Ll Distance to nearest: Well ^z Foundation" � Prope"—Line O DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and-that"the o k 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 followings"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." i The applicant must call for all required in pectians. Complete drawing on reverse side. Signed X�� _ ��,tCL.r1`Tit1e: Date: to DEPARTMENT.USE ONLY,.........,,..c Application Accepted by X Date S- l` Ty _ Area Pit or eln pection Date "tom Final Inspection bq� t�--L Date Additional Comments: © Stk 466-6781 ID Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE T P NO. a EH13-24 iREV. /s5) O S• EH 14-2e