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APPLICATION FOR PERMIT r - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone 12091 466-6781'1-' PERMIT EXPIRES 1 YEAWFROM DATE ISSUED (Comp fete in, Triplicate) i -r.u, i''�1 _ .•-4i ,;g„'~'., {,-.. ..?stf RC4 T :-. - "•' hApplication 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. i fir. Ind lid r4 ' J ` Job Address CYUY � City Lot Size PM I� Owner's Nameiv 17 Address V.�Itl. - Phone - ��,j�� ! �-rt1397-v [� / !I7krd3�-`,°t `a4�C4 2 Phone � - p v Contractor Address License No. .. TYPE OF WELL/PUMP: NEW WELL FT WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR LJ OTHER D r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE !E. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom g Manteca Dia. of W;II Excavation Dia. of Well Casing ..ET Domestic/Private ElGravel Pack L1Tracy Type of Casing Specifications ❑ Public ElOther ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth LJ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done— t Well Destruction ❑ Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is f available within 200 feet.) Installation will serve: ,Residence_ Commercial_ Other [ ! ' Number of living units: Number of bedrooms a r' Character of soil to a depth of 3 feet: _ Water table depth I SEPTIC TANK C1Type/Mfg ` Capacity .No,. ompartments "i I of-Di§j59§al 4 PKG. TREATMENT-PLT. d y � ✓ ' Distance to nearest: Well Foundation - - Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size' y I FILTER BED ❑ Distance to nearest: Well Foundation Property Line IK11— SEEPAGE PITS ❑ Depth Size t Number --SUMPS ❑ Distance to nearest: Well Foundation'^`--4' Property Line DISPOSAL PONDS ❑ 1 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 I rules and regulations of the San Joaquin Local Health District. f 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 California." The applicant ust call r I required inspections. Complete drawing o aver�seside. Signed Title: +'' Date: FOR DEP RTMENT USE ONLY Application Accepted by v ' Date Pit or Grout Inspection byt" Date Final Inspection by Date! =Additional Comments: ❑ Stk 466-6781 ❑ 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 FEE AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMlfk. INFO + EH 13"24(REV. EH 1428