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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA 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. f �J Job Address QQ / s �3 l r ()i I��,'� `\,J City "d 1 Lot Size PM Owner's Name u S F,CST 1 Q ,,r r COWP V' 1 Address —�� 3 Sa.�t-� � � � �r ti sLD Phone �l�+�t-ISiQr�++WS�C1Q! Intl I D,,Ja1p S�RL� 1ni- G Contractor lR -b AASc` Address ,Z5r ' sId+1 .blt 11�04 License No. q L 25X Phone TYPE OF WELL/PUMP: NEW WELL , WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ( is Ar1r C 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 k0 Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing4l"a kjQ NL Specifications ❑ Public ( Other&-�rr•lhr] ❑ Delta Depth of Grout Seal Type of Grout AD a, ❑ Irrigation _J�"pprox. Depth ❑ Eastern Surface Seal Installed by -b Ln S Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') 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 CapacityNo. Compartments PKG. TREATMENT PLT. ❑ 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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. 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 California." The applicant call al u'ed i spections. Complete drawing onreverseside. Signed Title: 9C� Date: 4 / D A T USE ONLY Application ?In, Date Pit or Grout Date � / incl Inspection by Date /�Additional C •c� ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ T4cy Mimi Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATET PERMINO. + EH 13-2 (REV.1/85) EH 1426 . �. �O �/\ 1A 5( `