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x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 -,(Complete in Triplicate) Application is hepeby 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 Local Health District. the Rules and Regulations of the San Joaquin Job Address t �� n I `� � } City_ SAl Lot Size PM � Owner's Name "Address 0_p •S Phone r� Contractor IQ,A #Wbdr,ss OJI, 6-J r''-'License No.PDQ!i/ Phone e i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION ❑ r +f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DIS?ANCE%TO NI=ARES SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V Cl Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing I ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout Ll Irrigation Approx. Depth El Eastern Surface Seal Installed by Repair Work Dane ❑ Type---Approx.of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO iNo septic system permitted if public sewer is Installation will serve: Residence Commercial— Other vailable within 200 feet.) Number of living units: ir^ Number of bedrooms t Character of soil to a depth of 3 feet Water table depth SEPTIC TANKType/Mfg 1 ` Capacity No- Compartments PKG. TREATMENT PLT." ❑ _ { Method of Disposal k Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines" T '�_ _ -ry Total length/size 1 FILTER BED ❑ Distance to nearest: Well c..Foundation Property Line SEEPAGE PITS ❑ Depth Size _ i Number SUMPS ❑ 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}p/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 I 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." I , The applicant ust all for all re mired i ctio Complete-drawing on-reverse-side: Signed X ry ��. Title: Date: ��p "FOR DEPARTMENT USE ONLY .Application-Accepted by.._--- _ - �—� Date ~� Area Pit or Grout Inspection by Date Final Inspection by Date o� ditional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O.•Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH j' 'L-,-5- + EH 13-24[REV.1/a 57 EH 1428