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x APPLICATION FOR PERMIT %R0 E,S SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone 12091 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Cornplete: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. Jab Address S r'"V /z�i/'IL/!�_ .ems City, / — Lot Size PM .. , .. . r Owner's Name F ress dr�� .f'yil�ss�/� Phone ` Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I/N PUMP INSTALLATION ❑ SYST REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE�I TYPE OF WELL PROBL M AREA NSTRUCTION SPECIFICATIONS ❑ Industrial w ❑ Open Bottom ❑ Mant a Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ' ❑ Gravel Pack 11 Tracy Type of Casing Specifications y ❑ Public ❑ Other * ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by " r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing terial (top 50') I Depth Filler Maters I (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL7L4TION ❑ REPAIR/ADDITION DESTRUCTION7,{No septic system permitted if public sewer is vailable within-200-feet.).. - ( � Installation will serve: Residence Commercial_ Other Number of living units: ' Number of bedrooms r.f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity�^^^"'"�"'`"`^ No. Compartments PKG. TREATMENT PLT. 0 _ Method of Disposal ' 4 1 Distance to nearest:.—_Well Foundation Property Line LEACHING LINE L� No & Length of lines Total length/site 1 ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line x f SEEPAGE PITS ❑ Depth Size Number `. f SUMPS ❑ Distance to nearest: Well Foundation Property Line .�t . j DISPOSAL PONDS (7 I 1. y . t 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 I I rules and regulations of the San Joaquin Local Health District:' j 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 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 mu ca for all req - d i pe -on Complete drawing on reverse side. j ' Signed X ` - � – �_ .. _,. ,.- Title: -^- 0-6��... _ . _ .Date:_ C]'C"� a-. --- ^-� --�--- FOR DEPARTMENT•USE-ONL-Y Application Accepted by Date r) Area v T Pit or Grout Inspection by - Date Final Inspection.by Date Additional Comments: tk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 AppEl - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, Stk., CA 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY ,J DATE P(EERM1T'lNOO.. + EH'13-24(REV. /Ab) EH 14-28