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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 s 1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �! ��J (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. 1-- 3 f20 G! i Job Address r ��L City LoA) �4MJT_CCA- t Size �� 27PM ,QUA VV � � `Address°12.16 V+� i F} C! Phone Owner's Name / 7 License-Na` /d —Phone � v Contractor A�`dress"- 2"r- - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT,El -DESTRUCTION ❑ t PUMP INSTALLATION Of SYSTEM REPAIR LJ--, OTHER ❑ DISTANCE TO-AEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE D FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1P � INTENDEO USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATI / d— f rl ❑ Industrial ❑� O�pen.Bottom anteca Dia. of Well Excava io Dia. of Well Casing �J1 f�mestic/Private Pr6ravel Pack ❑ Tracy Type of Casing Specifications �L (`l Public F1 Other ' %11 Delta Depth of Grout Seal l__ Type of Grout _ 1 1 Irrigation �_Approx. Depth "I i Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump �� H.P. State Work Done_ Well Destruction ❑ Well Diameter * ' Sealing Material (top 50') f Depth Filler Material (Below 50') �� ` TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is # ki rr 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 Capacity No. Compartments ; PKG. TREATMENT PLT. U. _ T Method of Disposal I Distance to nearest: Well Foundation Property Line f " i 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 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS s ❑ 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 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 certifiers the46116wing: "I certify that in the performance of the work for which this permit is issued, I shall employ per subject to workman's compensa- tian,laws of California. F The applica ca al re Ir i pe ns. omplete drawing o r reside Signed Title: " Date: 1 FOR DEPARTMENT USE ONLY y Application Accepted by 9,a DateAt3 ki 3 13-7 rea AV - Pit or Grout Inspection,by __ _ . . .. _pate,. -Final_Inspection-by_ --..Date_ - - Additional Comments: Ory ❑ Stk 466-6781 ❑ Lodi 369-3621 J ❑ Manteca 823-7104 '-' O Tracy 835-6385 .,,,,,,,„,,.Applicant__Return.all_copies to:_Environmentat-Health Permit/Services 1601_E._4azelton-Ave.—P O.--Box-2009-Stk.;--GA-95201 EEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦ EH13-24(REV.1iH51 -70 O EH 14- ti