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za r ,GS APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 NZ V,e. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C (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.. ,/;- _� 1 Job Address �� U�'► - City&Q_, . Lot Size PSN Owner's Name Address I&Zl A Xe « Phone 4 T Contractorl��y/0�2_ Addressal*f/Q AgA42Clz li ' License N r , / !Fahone b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �y1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q4 ❑ Industrial ❑ Open Bottom ❑ Manteca -_"Dia. of Well-Excavation-^- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j ❑ Public ❑ Other ❑ Delta Depth of-Grout Seal ; Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. .State Work Done Well Destruction ❑ Well Diameter Sealing Material Atop 50'1 Depth s Filler Material (Below 50') -- i TYPE OF SEPTIC WORK; .NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is f " available within 200 feet.l Installation will serve: Residence—' Commercial— Other Number of living units: t Number of bedrooms ; Character of soil to a depth of 3 feet: `"`" Water table depth SEPTIC TANK ❑ Type/Mfg aril+! Capacity __ No. Compartments PKG. TREATMENT PLT. ❑ r "" Method of Disposal DistancAo nearest: Well Foundation "Property Line LEACHING LINE ❑ No. & Length of lines Total length/size z FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth ? Size Number SUMPS ❑ Distanceto nearest: Well ` Foundation Property Line DISPOSAL PONDS ❑ 1 I' 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 emplv��persons subject to workman's compensa- tion laws of California. - -T The applican must call for required inspections. Complete drawing on rreve e,ssiidde. Q �Q Signed `Titl4: 1' / /1r2.� r _ Date: [�._ Gl,_� FOR DEPARTMENT USE ONLY I Application Accepted by Date �r�� Area Pit or Grout Inspection Date Final Inspection by Date k Additional Comments: Ale ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE: A�MjOUNT REMITTED CK / RECEIVED BY DATE PEFtM1T'N0. + EH 13-24(REV.s/s5) �� v�4 � O �/L.� �.- f EH 14-28 J�! / / .r