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APPLICATION FOR PERMIT r SAN .JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE 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. Job Address _ 1 L Y'1 City Lot Size " F M jt� 7� fh �Lf 2 0 Address cls�3�ahone � -7- 3 7 . Z_ r Owner's Name tl ' Contractor t{ G4ddress q&q F'"1 a- 12-t-04. t License No. 13 3 Phone ,�/� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ C- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r d f'1 Public C] Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlAbbITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet-1 Installation will serve: Residence X "Commercial Other Number of living units: Number of bedrooms j Character of soil to a ep h of 3 feet: ,t'z Water table depth SEPTIC TANK Type/Mfg dt� "` `f Capacity-/ No. Compartments PKG. TREATMENT PLT.❑`- `h U _ 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 ti SEEPAGE PITS �y Depth Size z Number 2— SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t I hereby certify that i have prepared this application and that the work will he 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 foilawing: "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 issuedr i shall employ persons subject to workman's compensa- tion laws f Calif m The applica u t for k r din coons. o ate drawing on reevrs e side. Signed X Date:Title• � -, FOR DEPARTMENT USE ONLY Application Accepted by �_ ,7? Date Area 14orGrout Inspection by D Final Inspection bl� Dated Additional Comments: �{ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy a35-6385 f Applicant - Return ail copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,,l 5201 pp''�� FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO 1 � INFO ♦ EH13"24iREV.t1>a5Y av EH 14-29