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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA j 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 Local Health District. P / Job Address r t� -6► IA Z6 City b �+' Lot Size PM Owner's Name I r► - 1'" �9y� Address ►f'� o� .[] n4"'4"'Phone Contractor's Name License'No. ~� one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ STRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ pelta Depth of Grout Seal Type of Grout El Irrigation ---Approx. Depth ❑ Eastern - Surface Seal Installed by Repair Work Done s❑ Type of Pump H.P, State Work one p d Well Destruction 1r Well Diameter Sealing Material (tap 50') III Depth -�"�t]h Filler Material (Below 50') f' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ( Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth I Size Number SUMPS . [IDistance to nearest: Well Foundation Property Line 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 JoaquinLocal Health Distr'ict: 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 became 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." t The appli=mustr all;aq ins Its. Co Oete drawing on reverse side. Signed Title: W2V Date: FOR DEPARTMENT USE ONLY Application Accepted by �� --qq Date � Area Pit or Grout Inspection by +G '�' Final Inspec on by T Date r dditional Comments: 7 L 'w/✓ ty �Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy Applicant- Return all copies to. Environmental Health Permit /Services/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH EH RECEIVED BY ��--77 DATE PERMIT'NO, + EH 114126 3-24 4REY.101631 I� 1 ~l "f Y ` Lj�I - `�J vV` R `l