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.wr.r d APPLICATION FOR PERMIT .r+ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Sari 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. Job Address City Lot Size PM t � , P11one� /(Owner's Nam Address _ a I A�M V� Contractor ku 60.J.." Cf. -fes Address; / �� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 36 r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ �O �� 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 1 ❑ Industrial ❑ Open Bottom r ❑ Manteca Dia. of Wall Excavation Dia. if Well Casing . #, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s F] Public E3 Other r 4 El Delta ;>Depth of Grout Seal Type of Grout ❑ Irrigation �pprox. Depth ` ❑ Eastern Surface Seal Installed by V. tate Work Done k Repair Work Done'..❑ Type of Pump H.P.HPWell Destruction "� Well Diameter f f Pik I Sealing Material [top W) f • Oepth 60 Filler Material (Below 501) • m TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCTION _I (No septic system permitted if public sewer is i available within 200 feet.) installation will serve: Residence (Commercial_,v.Other r QNumber of living units: Number of bedrooms Character of soil-to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. 171Method of Disposal l Distance to nearest: Well Foundation Property Line LEACHING LINE .. ❑ No. & Length of lines Total length/size FILTER BED ❑ 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 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." Thea st ca11 for wired inspections. Complete yawing on reverse side. 7 r 1 Signe Title: %`Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area j Pit or Grout Inspection by � Date Final Inspection by r! \�dditlonai Comments: # `�] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED -CW-SH RECEIVED BY GATE PERMIT NO. INFO _ f �']��1 a EH 1324(REV.1/0 5) D } 3 �•V .-3-709 !�i-� 7—{0 r 1� ! r r EH 1428 � y_