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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 rs 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. �n Job Address) L'41 "r C �w` -d '�` - City Lot Size PM Owner's Name gl�l kJ"-- , ' `'�f��i0 �Q%'Address r r t� �_- !_ .(/` P� t0 Contract C�L+A -l \ U MQ� �J nmress 1.3�'t v \ -hB'..I�c�"�License No. q1aQ Phone "-1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,BESTRUCTION ❑ 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 Wer Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Publi ❑ Other ❑ Delta Depth of Grout Seal Type of Grout rrigation --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 50') I r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system Permitted if Public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other n Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal A Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size IIUIf/ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 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 G 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 certifies the fo wing: "I certify that'1 the,6erfor once of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of ifornia." The applic - t ust all II re d ' g side. q specti n . Complete drawing ^ , cd.�zG lCl�p1 Signed Title: Da FOR DEPARTMENT USE ONLY Application Accepted b ? JET Date �2Area d *7- Pit or Grout Inspection rry ' // ' W. -}- Final I�nsspection/rbyy 1 Date Additional Comments: � �f�( (BLAI=el I t ( zI� PAkriCf, ffCO Z��A, Lr1W.��--"rLl�) 4Y)YyDyQ� /nr�,, ❑ Stk 466-6781 `�odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy —� v"u >,0N+?tPk • 'r Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 �y Gtr FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. NFO EH 132�IeEV.i/e51 <ZC , �/87 S7X EH 1Lffi `J �J O