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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. r IoOO /� Job Address ' o O f4 rl n 120 City klal� Lot Size PM Owner's Name r116 e I < Address Phone r Contractor— A= / Fu ft-ef— Address �G ��-_�j�° License No. Phone 1 TYPE OF WELL/PUMP: - - - NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ a. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 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 r Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ I 1 Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ G Well Destruction ❑ Well Diameter Sealing.Material (top 501 r" Depth Filler Material (Below 501 S TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION ESTRUCTION 1 I (No septic system permitted if public sewer is p available within 200 feet.) Installation will serve: Residence 4ZCommerciai— Other r Number of living units: __�_ Number of bedrooms —3 - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 9 LEACHING LINE No. 6 Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 r 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." Contractors hiring or sub-contracting signature certifies the following: "I 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." r The applicant must call for all required inspections. Complete drawing on reverse side. ♦ Signed X tjV .��.z'c� Title: c+J" Date: r VVV F MENT USE ONLY Application Accepted by R DEPARTDate � � Area �j1 r Pit or Grout Inspection by Date Final Inspection by Date�if Additional Comments: ❑ 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 r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT'NO. �. EH 1344(REV.rix 51 /� a 10 EH 1LM