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� I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. /�'�� r Lot Size o e-ew&I PM Job Address 'tCity e Owner's Name Address hone ` AddressP0,R �1�7 / e ZD Z.z� Contract �^ License No. Phone TYPE OF WELL/PUMP: ,,;? s tNEW�WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 -4_ 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 Type of Casing k, Specifications I71 Public ❑ Other 1.1 Delta Depth of Grout Seal Type of Grout—_ — i I Irrigation T Approx, Depth I I Eastern Surface Sea! Installed by - Repair Work Done L Type of Pump H.P. State+Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') a ` Depth — ler Material {Below 50'•) -- TYPE OF SEPTIC WORK: t NEW INSTALLATION i 1REPAIR ADDITION DESTRUCTION I I (No septic system permitted if public sewer is `// ---� `.r available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: --/— Number of be ooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r . r LEACHING LINE IX No. & Length-of lines Total length/size f b FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS X Depth Size = _ Nrmber S SUMPS El Distance to nearest: Well Eoundation . 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 perf6rinarice of the wibik`for which this permit is issued, I shall n 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;'1 shall employ persons subject to workman's compensa- tion laws of California." The applicantust calla!I r quired inspections. Complete drawing on reverse sid Signed X Title: Y r Date: �� 0(4 g© FOR DEPARTMENT USE ONLY Application Accepted by74 Date v ! A a or Grout Inspection by Date a12 final Inspection by e/� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. I INFO CASH pe--�� +.EH13.241rrEV.i/Hsl �� f,/—z�fp�� t��t�VlL1u EH 14-28 1 `��s`