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APPLICATION FOR PERMIT a l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA j Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Re ulations of the San Joaquin Local Health District. y Job AddressLI City Sr o_PO A Lot " e )cep*. M R _I Owner's Name I 0C 1C�rj5 _ Address Phone ConnP c _ ��j tractor l �� S��dress 15 R t9 _ License too. e7 `�J� P11one l TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR Cl PTHER ❑ DISTANCE TO NEAREST: SEPTIC TAMC IQQ 41- � SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _..._._L- AGRICULTURE WELL LhIQ OTHER WELL PITS/SUMPS 5V . I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ('Domestic/Private ® vel Pack ❑ Tracy Type of Casing P Specifications 1-1 Public ❑ Other Cl Delta Depth of Grout Seal < _ Type of Grout g 1 1 Irrigation ___Approx. Depth I Eastern qu1 a a Seal Installed by - Repair Work Done B Type of Pump M H.P. ' State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) .p � Installation will serve: -Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Cl--) SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C] Method of Disposal Distance to nearest: Well Foundation Property Line 004 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:F' Well Foundation Property Line �. Q- � it SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: " Well Foundation Property Line DISPOSAL PONDS ❑ 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. r 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,1 shall employ persons subject to workman's compensa- tion laws of Calif The applican m call for II required m5pections. Compla drawing on reverse side. Q� Signed X Title: Y 1lY�t�� Date: TMENT USE ONLY Application Accepted by a, y Date _ Area ©� a yPit o rou nspection by{ � Date-3— r S 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. Hazalton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT NO. INFO /� / CASH /l�.1/� y��/� + EH 3-24(RE 106,0-0 �vJ .a� �'"�� 0"7"gw`h ��- EH 14-28 V f I