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j i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT h 1601 E. HAZE`TON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED IComplete 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 11 Local Health District. f r Job Address i/ 01 P11V City �r� Lot Size PM r Address Phone Owner's Name -:_...,._ _ ..:.- .._ �. ._ ..,. n y , Contractor - Address' ? 1tY7lC 1 _ L.icense No. 125 Phone __TYPE-OF.WELLLPUMP' �„.,�._- .NEW WELL '❑ w WELL REPLACEMENT El. _DESTRUCTION ❑_ _ PUMP INSTALLATION 171SYSTEM REPAIR El OTHER ❑ mow .W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. � PROP. LINE ` FOUNDATION ;.AGRICULTURE WELL OTHER WELL PITS/SUMPS n ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' ' ❑1lndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation { Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ 1 I Irrigation _..Approx. Depth 1 i Eastern Surface Seal Installed by Repair Work Done ❑ T p ! p ype of Pum H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 - Depth Filler Material lBelow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is f / i available within 200 feet.) Installation will serve: Residence Ae Commercial— Qther 1A Number of living units: Number of bedro ms_ 1, Character of sail to a dept f 3 feet:"' Water table depth ;SEPTIC TANK 1Q Type/Mfg �� 1- /lG t e• Capacity_ Q_ No. Compartments f KG. TREATMENT PLT. ❑ -eu- '' y Method of Disposal Distance to nearest: Well 100 t+ Foundation 30 Property Line LEACHING LINE No. & Length of lines _ 6CKTotal length/size ry FILTER SED ❑; Distance to nearest: Well 1r�Q Foundation Property Property Line _ 1 SEEPAGE PITS I-I Depth Size Number SUMPS D Distance to nearest: ;WeII Foundation Property Line DISPOSAL PONDS = ".❑ 9' I hereby certify thacl'have prepared Tis application_and_thaI 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. 'y ' 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." The applicant must c 1 f r all reqWipections.' Complete drawing on reverse side. a Signed X Title: _ � Date: f s mF WP.ARTMENT.USE ONLY Application Accepted by. 14 _ 1% 1b Date /� Area Pit or Grout Inspection by Date Final Inspection by Date /, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 ` 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 CK RECEIVED BY DATE PERMITNO. INFO CASH + + EH 13-24 1REV.I/H 51 —7 C7 v EH 14-29.,—. .. / O.