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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 Regulations of the San Joaquin Local Health District.^ ' Z � � 3 52 7s7 1/1 Job Address i Lot Size PM Owner's Name III C a A o J./&�!KdclressSL^ -- 5� � rhbne CA/L 1115' Contractor / y� Address L j! icense fVo. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ /OTHEFf If DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION -----AGRICULTURE-WELL .QTHER WELD PITS/SUMPS INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial .54 ❑ Operi Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other CI Delta Depth of Grout Seal J Type of Grout-- I Irtigation rout] Irrigation .-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth ' Filler Material (Below 501 d TYPE OF SEPTIC WORK: NEW INSTALLATION I I RFPAIR/ADDITION I I DESTRUCTION f (No septic system permitted if public sewer is {`} available within 200 feet.) �M{� Installation will serve: Residence_ Commercial_ Other I 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. ❑ '� Method of Disposal Distance fo nearest:Weil Foundation W Property Line r _ LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation L. Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS ❑ Distance to nearest: Well - .Foundation Property Line DISPOSAL PONDS El 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. r-' d 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 7 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 t call for all re wired inspections. Complete drawing on reverse side. Signed _Title: ��fJ Z r� Date: FOR DEPARTMENT USE ONLY Application Accepted by CIS ___ Date A ' ` R-EArea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments::W1, i ❑ Silk 466-6781 It Lodi 369-3621 o�. .- Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return afl copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ~ CASH CK RECEIVED BY DATE PERMIT*NO. INFO 1 [//�// �}�� /` , +.EH13-291REV.r/H5J �7 Jb,jS VL � (� ( �8�� t!<f i EH 14-26 L� 1 (((!!f coCC�I� l f 1