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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZEL T ON AVE., STOCKTON, CA w ` Telephorie (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) T 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 F,'I made in compliance with San Joaquin County Ordinance No,549 For sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District- Job Address City Lot Size PM ` Owner's Name S/.ITN J_�NSa,40 Address C Phone 19,2211 Contractor T!7/I&",S rj J.�,Uoz - Address /V&U License No. Phone f^# I 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑. PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER O 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 Wel! Excavation Dia. of Well Casing �f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l-1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth ( I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ } Well Destruction ❑ Well Diameter Sealing Material (top 50') I — Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION is RE-PAIRIADDITION DESTRUCTION I I (No septic system permitted if public sewer is " available within 200 ieet.} Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms"- Character edroomsCharacter of soil to a depth of 3 feet: Water table depth i j SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments J PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to neatest: Well Foundation Property Line 1 r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Dept Size ��',,!�_K Number SUMPS 7' Distance to nearest: Well cFoundation AD Property Line _ DISPOSAL PONDS ❑ I hereby certify that 1 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 �r 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 compensa- tion laws of California." The applicant;�ustcall for all required inspections. Complete drawing on reverse side. Signed X Title: Date: _ 0/ p FOR DEPARTMENT USE ONLY ^� _ Application Accepted by �1 T Date ` a0 Area.-__ IJ__ lC Pit or Grout Inspection by Date Final Inspection by _ Date ! L t Additional Comments: El Stk 466-6781 LI Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 _ i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9526FEE L INFO AMOUNT DUE AMOUNT REMITTED ASH CK v RECEIVED BY DATE ERMIT NO. c7z- t 'a �� y JJJ� ♦.EH 13-24 tREY.r i x si - 'TI +1,53 //� / IY/ EH 14-28 /// W /