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II I ' I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA I Telephone (209) 466-6781 I� 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 applicat+on is j 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 1 Local Health District. Job Address3 1 ) City Lot Size �s7`y Z �3Jr M-7 E Owner's Name Address a®a CA.4 �.l "y4,i, _ Phone -7q d 4 z Contract Address y License No.326 Phone 6� TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ► 1 DISTANCE TO NEAREST:.SEPTIC TANK, SEWER LINES DISPOSAL FLD. ,PROP. LINE. t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r �. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing L ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ I i Irrigation _Approx. Depth t 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Q Well Diameter Sealing Material (top 501 Depth-ll Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW,INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is Iavailable within 200 feet.1 Installation ilisenie : Residence Commercial_ Other Number of iiving,units: II Number of a rooms Character of soil td-:a depth of-3--feet:_ _ Water table depth .� SEPTIC TANK < Type/Mfg - Capacity-412 0 0 No. Compartments PKG. TREATMENT PLT. ❑`u - �= i r Method of Disposal „ Distance to nearest: Well Foundation 1d Property Line LEACHING LINE No.'�Lengtl:,of lines — �t Total length/size d, w K j -FILTER BED- 4 C3 Distance to nea er st Well Foundation � Property Line z for SEEPAGE PITS t)epth Size"'* Number ,j SUMPS' �"" .* ❑ Distance to-ne�rest: "Well °`�`Foundationw'�b r' —PropertyLine�j J1- # DISPOSAL PONDS ❑ 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 r rules and regulations of the San Joaquin Locel Health Dr%trict�� f 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_beconievsubidict to workman's compensation laws of California." Contractor's hiring or sub-contracting signature }, certifies the following: 1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." r ; The applicantcall for al Muir inspections.,-Complete drawing on reverse si Signed X Title: ' Date: -SCb4,giq2-_ II `X FOR DEPARTMENT USE ONLY Application Accepted by Date��_, Area / IE it or Grout fns coon b -ae1 f?'7d �>� Date _ -� pe I L Final Inspection by Dat Z I Additional Comments: I� r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6365 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II ) I I INFO /AMOUNT DUE AMOU/�NTT REMITTED SASH RECEIVED BY �n�DATE PERMITK It �NO. y +.EN53-241REV.1/115 ��` ��/v K �� ! ��' r EH 14-28 ( -� � V O' 'li e