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APPLICATION FOR PERMIT f _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Local Health District. Job Address 7 ! S u r City ` Lot Size_ 0 PM Owner's Name + tU i-1 Address r Phone ` i t `r� ' -Contract-ar--yeti _ ._l-� S Address } � �=�• _. . ._ ._License No. �1_Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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,Excavation ' Dia. of Well Casing � "❑ Domestic/Priivate �❑ Gravel Pack ❑ Tracy tIoe of Casing -4 Specifications 1 Public / ❑ Other i 171 Delta -7 j I ,Depth of Grout Seal I Type of Grout — I I Irtigation1d. i Approx. Depth I 1 Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. State Work Done _ l� Well Destruction LJ Well Diameter ? Sealing Material [top 5071_t Depth I Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION [li REPAIR/ADDITION 1 3 TRUCTION F 1 INo septic system permitted it public sewer is { available within 200 feet.) Installation will serve: Re I'd ence ommercial— Other x; t r� Numbet of living units: Number a bedrooms l!1 + .. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t CapacityNo. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines' 'z Total length/size FILTER BED ❑ Distance to nearest: r Well Property Line t ass SEEPAGE PITS L_�I �Depth � Size � Number SUMPS tt—Distance to nearest: Weil Foundation L Property Line % :3 DISPOSAL PONDS ❑ 1 1 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 District. 4 ' Home owner or licensed agent's signature certifies the following:-1: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 becomesubject to'workman's compensation laws of California." Contractot'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- ton of Califom' ' ' The applican st cal�fa quir in late drawing on r verse sid . Signe (� x ' 3 Title; Date: F. '.r.rft. : a (FOR DEPARTMENT USE Of1ILY I t `j" Application Accepted.b --= f` Date Area r , .- Date `��" speciontby Date Pit or Grout Inspection y Final t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy .835-6385' I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNTif EMITTED CK 40 RECEIVED By DATE PERMIT NO. INFO CASH +-EH7 13-241REV.rik5f he - EH 14-26 ; a