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1p`l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 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 Health District for a permit to construct and/or install the work herein described. This application is made in compliance with Sart Joaquin Cou.;ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. OGS O L ` 1 Job Address ` City le am,ev��•6t Size � L� PM L� �LCfa'L Address —�� 1? !r ^7 3 5 Dwner's Name T z /— ' ^ Phone/ Contractor 4-F� • 4�V 4� -- Address__&_ Jr3 _ License h!o✓7.�D'&5 Phone ? _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ---PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE 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 Fl Public n Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation "r,: _.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of•Pump H.P. State Work Done — Well Destruction x© Well Diameter; Sealing Material Itop 50'1 Depth Filler Material (Below 501 t,\;,TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve!- Residence ie"Commercial_ Other w Number of living units: Number bedrooms 3 ; Character Of soil to a depth of 3 feet:' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 002dee No. Compartments L.1, R£ATMENT PLT. _ /�� Method of Disposal Distance to nearest: Well J -ir" F l0 0 ,. mandation Property Line _L4 VP LEACHING-UNE No:S.Lengt f�lines Total ler)gth/size p FILTER BED ❑ Distance to nearest:' Well Foundation + Property Line_L LLT SEEPAGE PITS I I Depth Size Number SUMPS &0"'Distance to nearest: Well 1262 Foundation s Property Line DISPOSAL PONDS Q Y 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 Di3tricl. 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."Contractors hiring or sub-contracting signature 1 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 call for all require3lipspections. Complete drawing on reverse side. f Signed . Title:- r Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by J Datd*,//- ?' k Additional Comments: ❑ Stk 466-6761 ❑ 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 *' 11C FEE INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED BY DATE PERMIT'NO. ♦.EEH}�-H W21IRt1l.riw6lle "70` oV -70,00