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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Joh Address Ch 21-(if City_13AQ4 Lot Size PM Owner's Name Address " Phone Contractor f } 1 U Address 2.120 WA C6C3Gt License No,A6611, Phane l♦ 3Z16 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION )(ft0,4Cuy*,I,*YSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER.WELL __PI_T_S/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 /f")•Public ❑ Other 1 ❑ Dela ,i Depth of Grout Seal Type of Grout I i IrricJation _.-Approx. Depth { I Easternty 1 Surface Seal Installed by Repair Work Done ❑ Type of Pump 4 H.P, Z State Work Done Well Destruction ❑ Well Diameter ` Sealing Material (top 501 4 Ilf t Depth ` Filler Material (Below 50'1 r > e _ TYPE OF SEPTIC WORK: NEW INSTALLATION-I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence Commercial_ Other r Number of living units: Number of bedrooms V 1 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 © y Distance to nearest: Well FoundationProperty Line LEACHING LINE ❑ No. & Le gth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth L Size Number -� SUMPS— � 0„-_Distance to nearest: Well.,. Foundation Property_Lines DISPOSAL PONDS ❑ ryryry I hereby certify that I have prepared this application and that 1hB work will be done in accordance with San Joaquin county ordinances, state laws, anc rules and regulations bf•the San'Joaquin Local Health District. /3 Home owner or licensed agent's signaturecertifies the following: "1 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 h- 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 s j'bct to workman's compensa- tion laws o 'fornia." I The app cant l r a uired inspections. Complete dr p g-a verse side. � SignedDate: 'Z 98� ' R DEPARTMENT US ONLY J Application cepted by 401, Date/ / Area s7" `/ rr� Pit or Grout inspection by Date Final Inspection by Data c7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Enviionmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEEf INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT N0. CA$H +,EH13.24 iREV. EH 14-26