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t APPLICATION FOR PERMIT I I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES .1 YEAR FROM DATE ISSUED L, I -!: (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. ' Jab Address A /�i�' S �•(•r(�Q - C C; City Lot Size PM - . dPh Owner's Name Address 7 � e 3 — 1 Contractor Address • License No.j2 _Phone , TYPE OF WELL/PUMP: V NEW WELL d WELL REPLACEMENT ', DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1,.f SEWER LINES DISPOSAL FLD./M" PROP. LINE M FOUNDATION AGRICULTURE WELL OTHER.WELL- PITS/SUMPS_ - ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tz ❑ Industrial ! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private )(Gravel Pack ❑ Tracy Type of Casing Specifications t ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Type of Gro t ❑ Irrigation --Approx. Depth ❑ Eastern. Surface Seal Installed by i "Repair Work Done EJType of Pump H.P. State Work Done ' r Wel! Destruction ❑ Wel! Diameter Sealing Material {top 501 1 Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to"a depth of 3 feel: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS E. Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 j 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 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 Calif rnia." f The applic t st call for all requiryg inspections. Complete drawing on r arses e. Signed Title: A�LLlW Date: 7127 r FOR EPART ENT USE ONLY J Application Accepted by y Date Area � 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: rev d✓ K (G 011 5l � ❑ Stk 466-6781 ❑ Lodi 369=3621 ❑ 4anteca 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 C H RECEIVED BY DATE PERMIT`NO. INFO + EH 13-24(REV.i/s 5) �. EH 14-26