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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZE,I ON AVE., STOCKTON, CA Telephone (2091 466=6781 PERMIT EXPIRES1 YEAR"FROM DATE ISSUED ` Com let { p e iri'Tripllt;ate}" _ y� J I L. r 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 j made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. Job Address " City a' rr fLot Size `I PM �7 -Owner's Name Address ?f �w r =_ ,x ,f:'Phone Contract f L Address Gam! ` / '/ � ,�` ,3sclS tate �"S� f License lye Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-;d ti DESTRUCTION ❑ W a PUMP INSTALLATION. ❑ SYSTEM REPAIR ❑ OTHER ❑. DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL D------ PROP. LINE alp FOUNDATION AGRICULTURE WELL -/-OTHER WELL PIT S/SUMPS1 INTENDED USE TYPE OF WELL PROBLEM ARE=A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom IfManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i, ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---4pprox, Depth ❑ Eastern Surface Seal Installed by " Repair Work Done ❑ Type of Pum i } r� p Yp P H.P. State Work done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION L7 (No septic.system permitted if public sewer is Q �� "' ° available within 200 feet.) Installation will serve: Residence J Commercial= ther a Number of living units:._., Number of be rooms Character of soil to a depth of 3 feet! � ^�. Water table depth SEPTIC TANK ❑ Type/Mfg Capaclty 'No. Compartments PKG. TREATMENT PLT. ❑ r n ' Method of Disposal Distance to nearest: Well Foundation--_ property Line LEACHING LINE No. & Length of linesT�r! length/size— FILTER BED ❑ Distance to nearest: Well_� _ Foundation Pro e ` - r - p rty-Line f SEEPAGE PITS ❑ epth Size �( dumber SUMPS ® Distance to nearest: Well Foundation /..L�_ Property. DISPOSAL PONDS ❑ I f `/ 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. r' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of.ihe 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." L The applicant st call for all ui ��inspecti�ons. Complete drawing on reverse ide. Signed Title: Dater FOR DEPARTMENT USE ONLY " Application Accepted by Date—. -1 Area Pit or Grout Inspection by Date Final Inspection by ar:jf Date Additional Comments: a?/� ❑ Stk 466-6781 IJALodi 369-3621 ❑ Manteca, 823z7104 ❑ Tii cy s 6385-f , Applicant- Return all copies to: Environmental Health'Permft/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk.;CA 95201 CK INFO AMOUNT DUE AMOUNT REMITTED _ -CASH RECEIVED BY . DATE PERMIT"N0. + EH 13-24(REV.t/_H5J EH 1426 - ` �4 - .> wv.-. `-- -— .._ s......, - S I •--. ,-mom.. .. -...