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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. Q .fob Address � I. �e. City Lot Size '] ply Owner's Name Address ' 2 Phone < Contractor 740 aa< ' � dress 1✓ 4 Pte»A ir i3� _Z3 _License No._ Phone °TYPE OF WELL/PUMP: -NEW 1NELL'O ``UVELL REP CAC f NT-0 — '-_'DESTRUCTION��7 tt PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAMC SEWER LIN S DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU E W LL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation ! Dia. of Well Casing `❑ Domestic/Private } {❑ Gravel Pack ❑ Tracy T pe pf Casin r J f� Other g Specifications f l Publil ' ❑ Delta D pth of Grout Seal t Type of Grout I i Irrigation { } � � s ----APProx. Depth I ] Eastern S ace Seal Installed by - 'Repair Work Done ❑-�j Type of Pump{ P. State Work Done I Well Destruction ❑ Well Diammeter' � � ! F � Sealing Material (top 50'} F Depth Fiber Material (Below 50'1 TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION IJ DESTRU TION )K IN septic system permitted if public sewer'is I avada a wit 200 feet.) f Installation will serve: Residence —I Commercial— Other I } s Number of living units: Number of bedrooms j € Character of soil to a depth o1 3+feet: /a&W-et1ater table depth SEPTIC TANK EIType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Id r s .1 i Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No.& Length of lines 4 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ;SEEPAGE PITS I I Depth } Size ��- - _ Number SUMPS fI Distance to nearest:, Well Foundation Property Line ,DISPOSAL PONDS---G— .1 ONDS ❑—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-'HealtFi District- f Home owner or licensed agent's signature certifies the following: '9 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 corhpensa- tion laws of California.- r ' The applica must call f require inspections. Complete drawing on reverse side. { f Signed X Title: i _ Date: y FO EPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data + 7 J Final Inspection by Dat r t/� 'Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 IJ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I r FEE AMOUNT DUE AMOUNT REMITTED CK 0 a,EH 13 _INFO ,,,,GASH...-.—RECEIVED BY,DATE, � ,PERMI7:N0.., 24(REV.1/H 5) EH a-26S w