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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „ I (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 o Local Health District. e `� Job Address / 03 E City Lot Size PM ' Owner's Name AW&KE Address Phone 5 .$ Address License No. / Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION jj)Z,'09AYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I TYPE OF WELL 1. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom '� Manteca Dia. of Well Excavation Dia. of Well Casing PODoinestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout !I 11 Irrigation : Approx...Depth—EI-Eastern Surf ace Seal-installed by + Repair Work Done ❑ Type of Pump H.P. State Work Done JF=754 T i� Well Destruction ❑ Well Diameter Sealing Material Itop 501 :I 9 Depth Filler Material (Belovq-5011 `� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑' REPAIR/ADDITION 0-f'DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.} LN ' Installation will serve: Residence_commercial x Other +' Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: I "'` Water table depth SEPTIC TANKS r ❑ Type/Mfg `�j i'f Capacity No. Compartments PKG. TREATMENT PLT. ❑ {t Method of Disposal Distance to)nearest:1 Well Foundation Property Line LEACHING LINE F1 No. & Lenglh ol ilnes`�`"_ �`"" y`' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS j „—❑ ,Depth— -- ...... - Size Number SUMPS O-�FDistance \to\ne6rest N Well ~r Foundation Property Line - s y DISPOSAL PONDS , ❑ ^'� 1 I hereby cartify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state IaWsr and rules and regulations of the San Joaquin Local Health Distr-ict.— ,. 3Home 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 applicantt t* equi lions. Complete drawing on revers side. i Title: Date: Signed X , l FOR DEPARTMENT USE ALY , — f/ ;i +A /� Area Application Accepted by Date r I`. Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk` 466-6781 ❑ Lodi 3139-3621 ❑ 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH T RECEIVED BY DATE PERMINO. 35 oc� !>7 ly-�r _137� + EH 18-241REV, /851 EH C_� EH 1428 .s -