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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP T 3 � ^ PERMIT EXPIRES 1"YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) I PERMIT/SERVICES 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. ` I ! Job Address J�� t t IQ�t�t _ Sp ____ City Lot Size PM Owner's Name a 0.q;SXDIN& 1i7-A&^& Address 4 SAC)o C1\(A'1R'-4 _ Phone 310 9 -tz_ �'�/� p� Contractor �-- Address License e6 a65 71� 'Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION© PUMP INSTALLATION 17 SYSTEM REPAIR,< OTHER ❑ i DISTANCE TO NEAREST: SEPTIC T _ W�EWER I iNES USPOSAE FUD. PROP- LINE ANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-domestic/Private D Gravel Pack El Tracy Type of Casing Specifications i (`l Public { Cl Other Cl Delta Depth of Grout Seal Type of Grout 1 I I Irfigation —..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump __._ H.P. �. State Work DoneAcc Well Destruction ❑ Well Diameter Sealing Material (top 501 e t _ Depth a7/ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I 1 DESTRUCTION I 1 (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 II SEPTIC TANK ❑ Type/Mfg , Capacity No. Compartments �r PKG. TREATMENT PLT. ❑ , x Method of Disposal Distance to nearest: k Well Foundation Property Line LEACHING LINE ❑ No:& Length of Eines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Z . E H I SEEPAGE PITS 1 1 Depth Size Number SUMPS 11 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and"that the work will be done in-accordance with-San Joaquin county ordinances, tate laws, and ; rules and regulations of the San Joaquin Local Health District- f Home owner or licensed agent's signature certifies the following: "1 certify that in the perfbrmance of the work for which this permit is issued, I shall not 4 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 foil ing: "I certify that in the performance f the work for which this permit is issued, i shall employ persons subject„to•workmah's-compensa- i tion laws of C Ifo nia.” r ! The appli st call for all r fired ins ions. Complete drawing on revZ side. - I - �i I Signed X' Titre: LQ Date: I� 4 F 4 1 F DEPARTME T USE ONLY l� .-- Application Accepted by Data ~�! Area r"�J Pit or Grout Inspection by ' ,Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1.601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED+BY -,HATE - PERMIT;NO.. •.. -- -INFO CASH s +.EH13-24{REV-i/As1L-i �_? 110 EH 14.26 1 .L 1