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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA R 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 �,�/ p�,. City, / Lot Size xG Q PM .. Owner's Name J I /Y/, r /�i�C G _ Address ' Phone .7 �) ► Contractor_ /�i * " _Address License No. ,3-�. TYPE OF WELL/PUMP: i`, NEW WELL ❑ Phone M: WELL REPLACEMENT ❑ _ DESTRUCTION ❑ �T: UMIP INSTALLATION ❑ SYSTEM REPAIR ❑ k'DISTANCE TO NEAROTHER ❑ a,. SEWER LINES. DISPOSAL FLO. PROP. LINE I ' OUNDATION ULTURE WELL OTHER WELL F• PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CONS ❑ Industrial SPECIFICATIONS El Bottom ' ❑ Manteca `:y Dia. of Well Excavation —- ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy',;- '�. ,` Dia. of Well Casing I Type of fications ! ❑'Public ❑ Other ❑ Delta rk" Depth of Grout Seal -k F E Type of Grou ._.Approx. Depth , ❑ Eastern., Surface Seal Installed by_ i Repair Work Done ❑ Type of-Pump H .P. State Work Done Well Destruction Ll Well Diameter Sealing Material trop 50'} l Dept Filter Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑; DESTRUCTION (No septic system permitted if public sewer is 4 � s available within 200 feet.] r Installation will serve: Residece_ Commercial Other ' # k- Number of living units: Number of bedrooms r Character of soil to a depth of 13 feet: 0. 1I SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' .1 y Method of Disposal. Distance to nearest: Well Foundation Property Line r,. LEACHING LINE ❑ No. & Length of lines Total length/size` i, FILTER BED ❑ Distance to nearest: Well' - Foundation V 'Property Line l, SEEPAGE PITS ❑ Depth Size Number .SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ �� Property Line 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: "l 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 certifies the following: "I certify that in the performance of the work for which ermit is issued,I shall emof California." olnoY per is hiring c sub contracting signature tion laws of California." ;I p p Y persons subject to workman's compensa- tion The applicant m cal!f I ire Complete drawing on reverse side,. r Signed Title: ��/y 1 Date: yM ARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final I spection b ,3U - { Date Additional Comments: b :Te�•'�,�� A ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑.Tr acY 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk. t .�� , CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. F + EN 13-24 EH 14-26(REV.tinsl �yfd �d c'] . Oc7 _ +y r 1