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Q APPLICATION FOR PERMIT ` LJ* SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA '� vs 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 Local Health District. / /� Job Address �� ( _--- t--4/ — City Lot Size Owner's Name � / _� Address _ + 51 hone aT- Contractor Address--?—?� Lw License No.a"Wor—Phone TYPE OF WELL/PUMP: NE&WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /00 / SEWER LINES DISPOSAL FLD. PROP. LINE �QQ FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS Ajor INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation— 11 Dia. of Well Casing '(Domestic/Private Grave! Pack ❑ Tracy _ Type of Casin"g -/bL L Specifications 6 Public El Other "O Delta Depth of Grout Seal ---tType of Grou a ❑ Irrigation /�pprox Depth 4 Eastern Su ace Seal Installed by - el Y �l'n _ Repair Work Done ❑ Type of Pump Yk (2 H,P. ._ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') _ 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—t Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: —__ _ Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity_._ No. Compartments _ PKG. TREATMENT PLT. ❑ 1 Method of Disposal 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 1 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. r Home owner or licensed agent's signature certifies the following: "I certify that iR 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."Contractors 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 componsa- ��#tion laws of California." i -i The applicant must ca for u' Ing on reverse side. tee. ISigned X_ _ Title: , �1�� - Date: ..._�1„ f"�C3,t---' . r / FOR DEPARTMENT USE Of11LY ' T Ritz 1i Application Accepted by � t Date Area �y Pit o Grout I pection by Date -ys Final Inspection by Date 12� Additional Comments: ❑ Stk 466-6781 Ll 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH EH 5�241REV.1/951 SG �' .. nc� l��"71..r C•t_� S-39 4