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APPLICATION FOR PERMIT SAN JOAQUIN+LOCAL HEALTH DISTRICT 1601 E.'HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . T. (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 coritpliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules.and Regulations of the San Joaquin Local Health District. oJob Address f+1E- LT:- Q r � - 1 I Lot Size PM z - +'t '1,•1 �'i"tva �� :. #i �G. C-hr 1�K �' City �0 . Owner's Name Address iA r� 1� Mile ='Phone�=x Contractor's Name 0A0113P (C, UJW0 (%I—_ License No. p n "®9.0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,. DESTRUCTION 9i PUMP INSTALLATION ❑ ,SY_STEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER_LINES'X' 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 Excavafiom Dia:of-Weil�Casing { ID Domestic/.Private ❑ Gravel Pack._ ❑ Tracy., Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seams I a Type of Grout ❑ Irrigation s ---Approx. Depth ❑ Eastern Surface Seal Installed by S Repair Work Done ❑ Type of Pump H.P. State Work Done a Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION ElNDESTRUCTION El (No septic system permitted if public sewer is a available within 200 feet.) Installation will serve: Residence_ Commercial_ Other +A Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity; No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal i r Distance to nearest: Well Foundation y _ Property Line I 1 LEACHING LINE ❑ No. & Length of lines Total lerigth/sizet� '"`j:i� '� r'�"► + y R., FILTER BEd ❑ Distance to nearest: Well Foundation Property Line - k SEEPAGE PITS ❑ Depthk Size' C _z, -'�� Number #. SUMPS ' ❑ Distance to Barest: r Well ,Foundation Property tine 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 District. 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."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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for all re . d inspections. Complete drawing'on rd v!rap side. �! Signed Title: r ' iiir� pate: _ }( FOR PARTMENT USE ONLY f Application Accepted by ` Data �� "mss Area Z Pit or Grout Inspection by Date Final Inspection by Date ; v Additional Comments: .. . ❑ Stk 466-6781 E1 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE' PERMIT"IVO. )i INFO a EH 13-24 IREV.10193) ti , EH W29 'T.- _ �_n.