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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 17 ' 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. .� Job Address ��3-;u HWf, aCfe _ - City Lot Size LXA9,1,1�L , PM Owner's Name iUb-, fif�rn �* Address V3 Jf 1&.e '�t ��+-- !ems Phone Contractor AfUe �'.V&A"0r1gddf% iP22 e11a ��y f� '� License No.3n2 2, _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 si ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12-Ir Dia. of Well Casing 1 y If Domestic/Private 9Gravel Pack ❑ Tracy Type of Casing G � Specifications 71 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of.Pump H.P. 7 State Work Done Well Destruction ❑ Weil Diametera*— F Sealing Material atop 50') Depth 12b Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I'1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other - -- f Number of living units: Number of bedrooms. { Character of soil to a depth of 3 feet: " ` Water table depth SEPTIC TANK ❑ Type/Mfg r r apacity No. Compartments PKG. TREATMENT PLT. ❑ ' 1Method of Disposal a 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 I I Depth Size Number } � r k � SUMPS Ll Distance to nearest: Well Founda.r" tion Property Line DISPOSAL PONDS ❑ , 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. Ii_� 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." l I The applicant must call for all required inspections..=Complete drawing on reverse side. Signed X /1« itle: A2e/LZ_4e:;,' Date: FOR DEPARTMENT USE ONLY Application Accepted by I Date Area Pit or Grout Inspection by Date Final Inspection by G� �✓�� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 RECEIVED BY DATE INFO PERMIT'fl0. @�`! + EH13-24(REV.1 i H 51 Ica, � EH 11-28 1�\— Y 1 -1