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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 described. 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 _0-11 1i City "A,44 _:!L L�bE Size PM Owner's Name j. �-�",�+�s Address �� 5• I" Xghone Z � Contractor A Address_ �/��''1 `+`. License No, Phone TYPE OF WELL/PUMP:. i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUIMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ^ y 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 FI Public Iii Other Cl Delta Depth of Grout Seal Type of Grout _ f I I Irrigation �M' -Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Tye of Pump H.P. State Work Dane_ r Well Destruction ❑ Weill Diameter Sealing Material (top 501 Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION rDESTRUCTION [.I (No septic system permitted it public sewer is I - available within 200 feet.) Installation will serve: Residence Commercial_7_Other Number of living units: � Number of bedrooms Character of soil to a depth:of 3 feet: Water table depth SEPTIC TANK ❑ .Type/Mf I g Capacity No. Compartments PKG. TREATMENT PLT. LI :11. of Disposal i :'Distance to nearest: Well Foundation ` Property Line LEACHING LINE &1l"ONo. & Length of lines l '° diel length/size FILTER BED ❑ Distance to nearest: WelV_— Foundation Property Line I� SEEPAGE PITS I 1 Depth Size Number SUMPS L] 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 rules and regulations of the San Joaquin Local Health DFstrict. Home owner or licensed agent'is 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 mariner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: '9 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 must call for all required inspections. Complete drawing on reverse side. r .4 Signed I Title: Ln Date: 10/1 f FORARTME USE ONLY Application Accepted by .- Date Z. Area Pit or Grout Inspection b y I� Date Final Inspection b Date Additional Comments: 1� ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH13-2/1Rtv.t/R51 '5-76 rl x- EH 11-29 I�.