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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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: a G Job Address ` � `'L-'� � �- * City T Lot Size /CJS/ +Y PM Owner's Name ��'-- "� �'"'-Address 19�w` �'-• �- Phone Contractor 1-yN1S cX=7"itC- Addres ��'t'.`�1 'L40�I �z'�LicenseNa �P3�one�✓��t9� $ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Y Type of Casing Specifications ( (y LJ Public ❑ Other (I Delta Depth of Gout.Seal r _ Type of Grout lJ ❑ Irrigation ---Approx. Depth ❑ Eastern,' Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 4 ~ State Work Done O Well Destruction ❑ Well Diameter Sealing Material [top 50'') Depth Filler Material (W 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is $ available within 200 feet.) Installation will serve: R sidence Commercial Other Number of living units: = Number of bedrooms Character of soil to a depth of 3 feet: � u -" '' Water table depth SEPTIC TANK Type/Mf %ITti Capacity No,Compartments PKG. TREATMENT PLT. El R Method of Disposal rest: Well Foundation Property a Line Distance to nearest: o P rtY 1 , LEACHING LINE ❑ i"No. & Length of lines .. Total length/size FILTER BED E] { Distance to nearest: } Well ` Foundation Property Line _ SEEPAGE PITS ❑ , Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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. Home o er 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 rson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifi kthe fo win "I certify that in the ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laf Caii rr 'The apnt u t c f required inspections. Complete drawing on reverse side. t`Signed Title:� Vt.__ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date —�O 5C Area Pit or Grout Inspection by Date Finai Inspection by � F/�-�' Date : AJ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 AManteca 7104 ET Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l � t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH -70 r EH 13-241REV.va5i EH 1428