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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone 1209) 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 descr-(bed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �• // r �r City Lo.��' Lot Size PM Owner's Name r 1�/ "�IAddress � J `�'L"` G�^ Phone C- /3 Contracto i7�7 J Address & 1&g g 49 License Me l ---Phone �Y TYPE 0 WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ p PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ig�it /1�4 �L 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 71 Public ❑ Other 17-1 Delta Depth of Grout Seal Type of Grout 1 1 Irrigation --Approx. Death (1,Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump �' H.P. Zate State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION f I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence_ Commercial_ Other d Number of living units: Number of bedrooms ~ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 11 Method of Disposal Distance'to-nearest: Well Foundation Property Line I j LEACHING LINE ❑ No. & Length of lines Total length/size J FILTER BED ❑ Distance to nearest: Well Foundation Property Line f_. SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Diktrict. 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 C if nia." The appli mut ct " call r all quiinspections. Complete drawing on reverse side. Signed X Title: �9G'a�' Date: F DEP NT USE ONLY Application Accepted by Date Area Z12- Pit 1ZPit or Grout Inspection by Date Final Inspection by ��/� ''� Date r/ � Additional Comments: 1, eC&eAfi)% G V-1e,- "� w e ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7164 ❑ 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 I CK RECEIVED BY MATE YEf�MiT NO.� INFO I CASH 7 a.EH 13-24,;REV.t/N 51 �� W 76 �� •.2 q Z� \� EH t4-2e ✓ I` xv