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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE=L 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. Job Address 0/ �" �'e / City �fJ Lot Size PM ,.. �-µOwner's Name �lAddress's Phone I me ��/'C� �� V License No. Contractor's Nal Phone G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ DATE PERMIT"N0. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP. LINE n 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastein Surface Seal Installed by Repair Work Done L1 Type of Pump H. P. ,,-State Work Done Well Destruction ❑ Well Diameter Sealing Material p-50 b� Depth i -'� � ^- � Filler Material [Below 50') TYPE OF SEPTIC'WORK: NEW INSTALLATION; REPAIR/ADDITION Q DESTRUCTION ❑ Mo septic sysfem'permitted if pubficrsewer is j r ; available within 200 feet.) ''- ✓ z Installation will serve: Residence _ Commercial Other _ C0 .Number of living units: 1 Number of bedrooms -Character of soil to a depth of 3 feet: , Water table depth 6 f7EPTIC TANK ❑ Type/Mfg_ �- I Capacity_ No. Compartments \,, PKG. TREATMENT PLT. I /IMethod of Disposal 'Distance to nearest: Well Foundation Property Line LEACHING LINE FILTER BED No., rat Length of lines ❑ 1 Distance to nearest: Well oa e g Foundation Property Line SEEPAGE PITS ❑' Depth Size Number SUMPS Distance to nearest: Well `D Foundation �D Property Line DISPOSAL PONDS 71 '! I hereby certify that I have prepared this application and that the work will berdone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sart 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 Cali a." I - -4 The applicantu call for I require inspections. Complete drawing on rev side. 5Y Title: ' --Z/,,Z �y Signed Date: . FOR DEPARTMENT USE ONLY ` Date Area Application Accepted by Pit rout Inspection by - � /ate j 'Final Inspectign by -Die Additional Comments: — ❑ Stk 466-6781- ❑ Lodi 369-3621 ❑ Manteca 823-7104 • ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 [REV. 10183 .,. EH 14-28 w FEE' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. 11. y ��° fi n rt-a� ! gy51°�