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' APPLICATION FOR PERMIT 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 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. i Job Address ` YA itY Lot Size PM I 4 6 Owner's Name •s Phone cto Cantraf e No.A7_7��Phone Z t' TYPE OF WELL/PUMP: NEW WELL ss WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLA ION p/ SYST M REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS�FLD PROP. LINE __, r/FOUNDATION AGRICULTURE ELL OTHER ITS/SUMPS11 DED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA ndustrial pen Bottom Q Manteca Dia. of Well Excav n Dia. of Well Casing i, ❑ Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing , Specifications M Public FI Other Cl Delta Depth of Grout Seal Type of Grou I I lirigation —.Approx. De th I E`stem Surface Seal Installed by Repair)Work Done E-1 Type of Pump H.P. State Work Done_ Well Destruction ❑" Well Diameter Sealing Material (top 50') Depth 777 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION f I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Iristallation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEISTIG TANK ❑ Type/Mfg Capacity - No. Compartments V) -� PKG. TREATMENT PLT.❑ i Method of Disposal Distance to nearest: Well Foundation Property Line t.. a I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F ! SEEPAGE PITS I I Depth Size i; �( Number I SUMPS 0 Distance to nearest: Well Foundation Property Line 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 773 rules and regulations of the San Joaquin Local Health Di§trict. 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 compens tion laws of California." The applicant mu I or all r uir s q pecti . Complete drawing on r se side. I-- Signed X Title: Date: R DEPARTMENT USE ONLY Application Accepted by Date 'e�� ' �C j Area Pit or Out Inspection by ate r] s—�� Final Inspection by—� Date G f Additionaf Comments: ❑ Stk 466-6791 ❑ 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 1t } FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO �.E -2, / CA DATE P�E}'RMI�T7NO: � 1IREV�siKsl .. EstH„-26 I