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f APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Locai Health District. ..„ i — + Job Address �:. City Lot Size .�t�A4, PM Owner's Name Address X14W 1W Phone Contractor's Name n License No. JO 7.70 Phone '.3j 37 k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material (top 501 G Depth Filler Material (Below 501 G TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L/ Commercial— Other Number of living units: _t__ Number oi,bedroo s Character of soil to a depth of 3 feet: � ater table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Como i PKG. TREATMENT PLT. ❑ Method of Disposal-- Distance to nearest: Well Foundation Property Line t r 4 LEACHING LINE it No. & Length of lines /'t�� 1f A Total length/size 0 r FILTER BED El Distance to nearest. Well Foundation 1� ` Property Line L6sL �;•:., r ��,.,.. .tel .- SEEPAGE PITS 1!�- Depth Sizey b/� Number SUMPS ❑ 'Distance to nearest: Well 0 5 ' Foundation Property Line DISPOSAL PONDS ❑ ' 1 f 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:'T 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 call r ai required inspections. Complete drawing on reverse side. c r t Signed Title: Date:��'� l _ . - [ � FOR DEPARTMENT USE ONLY Application Accepted by Date Area -yy s 6� Pit or Grout Inspection by F Date Final Inspectiov n by '� Data 1� Additional Comments: t . ❑ 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 CASH tit RECEIVED BY DATE PERMIT"NO.' INFO + EH 13-24(A".70!83) 1.1 S. , C Y bC17pgS o 5'\O�O EH 1428 - - - --