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APPLICATION FOR PERMIT SAN JOAPUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA j Telephone (209) 466-6781 iI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II (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 well1pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address r �' I e a Pee; ,��• City �G 41, Size PM � II 11 _ Owner's Name l �-[ If�t� Address _544)1e— Phone " 7,04 Contractor l� rOCY/\ �Q1� UC'Addr�s91- � e � � 51LiCe� �ob� hone q3'-3b2 -TYPE OF WELL/PUMP: J1. NEW WELL ❑ WELL REWACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' j -0i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL.-,.OTHER WELL T PITS/SUMPS INTENDED USE TYiPE 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 M Public ❑ Other 1=] Delta Depth of Grout Seal Type of Grout I Irrigation 1!Approx. Depth YI 1 Eastern Surface Seal Installed by _ - Repair Work Done �❑ Typee,rrof Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION LI DESTRUCTIO No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence Commercial_ 'Other 3 rr[ G bell �rC, ►-" 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. ❑ ' ' Method of Disposal Distance to nearest: Well Foundation Property Line J 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 SUMPS 171 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Ip' 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�p rules and regulations of the Sari'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." Contractors 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." F I The applican u t cal al rip i ed inspections. Complete drawing on reverse side. 1 • Signed X Title: Date: I� FOR DEPARTMENT USE ONLY Application Accepted by __ 'M _ Date ^` 2 Area p� Pit or Grout Inspection by I! Date Final Inspection by Date 0 F ip Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 11 369-3621 ❑ Manteca -71 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1 E. Hazalton Ave., P.Q, Box 2009, Slk., C!A 95201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO t EH 13-24(REV.i i s 5) �- EH t4-2e � 9-7 !3�L �i ,