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'R APPLICATION FOR PERMIT L L/ SAN JOAQUIN LOCAL HEALTH DISTRICT j 0 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 p� ' PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) �.y ' 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. .g ' Job Address City ,_�� Lot Size PM e. .�4 f^ra f Owner's Name 1nTAddress SO1 Nk�� Phoney ` Contractors It,It !_u 1�e r »� Address w k License No.a2�X Phone r TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑i. DESTRUCTION ❑ l PUMP INSTALLATION'❑' SYSTEM REPAIR ❑ " —OTHER-0 DISTANCE.TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 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 t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irtigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth FilleFMaterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION t I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_-__ Other Number of living units: Number of bedrooms 1 �" ( Character of soil to a depth of 3 feet--'.-- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` I PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line o LEACHING LINE ❑ No. & Length of lines r Total length/size R FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest:t (Nell 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 rules and regulations of the San Joaquin Local Health Diltrict. 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 signatul certifies the following: "I certify that in the performance of the work fm which this permit is issued,I shall employ persons subject to workman's compensa- u tion laws of California." The applicant must call for all req .red inspections. Complete drawing on reverse side. I tke I Signed XTitle: A.� Date: FOR DEPARTMENT USE ONLY r13 Application Accepted by Date Area Pit or Grout Inspection by Date Fi spection by f 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 INFO AMOUNTDUE AMOUNT REMITTER K RECEIVED BY DATE PERMIT'NNO. r +.EH 1321(REV.r/n 5) —�'� C— ✓ /'�/�i EH 11-28 V