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APPLICATION FOR PERMIT 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 well/pump and the Rules and Regulations of the San Joaquin i Local Health District. v j Joh Address 12 + t' —� `fes t L City : Lot Size f-- --y. PM Y Owner's Name j ! _��f�? f",� Address [ 1 �� `, 1 �� Phone t 0 aa Contractor ' ? /k/Address P 40. �/5`� !V �icense No.�'7 f Phone TYPE OF-WELL-/PUMP: NEW:WELL,!Kr-- . _----,, u WELL'REPLACEMENT,:D--, __«_ DESTRUCTION...©.-- ,- PUMP INSTALLATI SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE fY FOUNDATION = AGRICULTURE WELL _ OTHER WELL PITS/SUMPS// INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r ❑ Industrial Open Bottom , ❑ Manteca Dia. of Well Excavation Dia. of Well Casing •� 1 Domestic/Private [:1 Gravel Pack .f f,,O Tracy Type of Casing e- Specifications �I f`l Publicf_]'Other n Delta De th of Grout Seal Type f Grouter r� t ' __ I t Irrigation g 3ZS�_Appra. Depth l:l Eastern S c Seal Installed by /4 Repair Work Done ❑ Type of Pump H. State Work Done'. S. , Well Destruction ❑ Well Diameter Seating aterial [top 50') ----Depthf r' Filler Material (Below 50') TYPE OF SEPTIC WORK;_NEW INSTALLATION I'] RFPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is } available within 200 feet.) t Installation will serve: Residence Commercial_ Other J: + Number of living units:------ Number of bedrooms r1 F Character of soil to a depth of 3 feet:'__J Water table depth SEPTIC TANK - '.0... Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No. 8r Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property.L•irie I SEEPAGE PITS I 1 Depth Size Number SUMPS,, Ll Distance to nearest: Well Foundation Property Line 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 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." Contractors hiring or subcontracting signature certifies the_following: "I 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 m st all for all required inspections. Complete drawing on reverse side. 1 Signed �(_ - �t ' Title: ��- ��C '� Date: ' FO DEPARTMENT USE ONLY Application Accepted by Date — Area Pit or CJfr/ut Inspection by� Date�177— � 1 Final Inspection by'T Date G L: x •-.�aAdditio(nV�al Comments: -•- --• ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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. CI +.EH t3-241REV.riHsf 11 �+� d 71.5 d EH 14.29 vd� 1 -L.o p�