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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. ��--_"p� � Job Address o City, dam+ Lot Size PM Owner's Name ai Address SIZPhone i _ 7 Contractor's Name License No. 2s ��3 L4 7 Phone Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION ❑ (No septic system permitted if public sewer is ++��//' available within 200 feet.) Installation will serve: Residence L Commercial_ Other Number of living units: Number of bedr o/fR/s / Character of soil to a depth of 3 feet Y 144� Water table depth SEPTIC TANK ❑ Type/Mfg LJ Capacity No. Compartments \ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1J\( LEACHING LINE �. No. & Length of lines { — Total length/size ZJe6 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS PI Depth Z�! Size 3 z! Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 l rules and regulations of the San Joaquin Local Health District. r� Home owner or licensed agent's signature certifies the following: "1 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 compensa- tion laws of California." The applicant must call for I requir Minns. Complete drawing on reverse side. Signed r N Title: = 29-�a Date: 0 Z OO FOR DEPARTMENT USE ONLY (� t Application Accepted by �A n - � ..—a[yi.;,g=-�-� Date 1d A S—� Area_d 47 Pit or Grout Inspection by (� Date (�Final lIInspection C'by Date Additional Comments: yw A, 1 1sa. .XYa-'�^'� ��ly,.,..t j - +ft�: •�'A ❑ Stk 46&6781 ❑ Lodi 369-3621 ❑ Manteca 8n-7164 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. I j Qo 0 11 � EN 1124(REV.10/931 �� li U1� � Ah/D\� ly)'—/C_FdI wi_!,