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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (2D9) 466-6781 SCANNED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- (Complete SSUED(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. ' F Job Address —�� 7 ' City Lot Size PM F-� Owner's Name d ' P`'f�6'1 Address Phone Contractor ��L Address y � �A License No: 27 V hone 0 � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ _,. PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS S I k ,. k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �k ❑ Public El Other El 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 50'1 l Depth Filler Material (Below_ :50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1-7 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) FilInstallation will serve: Residence— Commercial 3Other Number of living units: Number of hedrooms�— Character of soil to a depth of 3 �/�feet: Water table depth f� SEPTIC TANK [❑ Type/Mfg . Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method.of Disposal Distance to nearest: Well Foundation Property Line` I � �} LEACHING LINE ❑ No. & Length of lines Total length/size d FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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. j Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not II 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:"l 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." / I � Ca The applicant m st call or allvrequired inspections. Complete drawing on reverse side. �' Signed Title: ��t1 Qom- Date: I! i f,J � ffl9hR DEPARTMENT USE ONLY Application Accepted by Date Area "Z Pit or Grout Inspection by Date Final Inspection by Date 7 Additional Comments: ❑ Stk 466781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 F 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 RECEIVED BY DATE PERMIT`'NO. INFO //^� F5 + EH 13-24 EK 1426(REV.IZ65) 7�,�� j (� do 1 a / // 7 7-A