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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. /re-Fao (.".", Job Address _ -�N�A-- - -- City Lot Size �� tiSPM — Owner's Name awI"�y Address v �1/_ I - Phone` � O �O � J OO<D�UV No lsisl Phone Contractor Y K �ob� Address License TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER P< 50Ij_VAPb{Z VPZ%S DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE y F4N8Lf_ 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 M Public 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 fc� Well Destruction I-- Well Diameter — --- b' Depth Filler Material { _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Instalfatibn will serve: Residence_ Commercial Other Number of living units Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg __ __ _-_. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line — LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED .r ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0/01i, Ll 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 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's eompensa tion laws of California." The applica mu t ca I o It rregqu�ired�inspections. Complete drawing own,re/vers�e,�sii�dee.. 1 / Q Signed X= 1v^_ 1�'-1_f-`Lr=` z Title: A_l -r�"��-- Date: —f a( ��_ FOR DEPARTMENT USE ONLY / G Application Accepted by /� __ Date` liZj p Area _Q- Pit or Grout Ins y _ Date Final Inspection by "` _ _ Date a �� Inspection b Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 Manteca 823 7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental HealthSes 1601 E. Hazelton Avg_, P.O. Box 2 A 95201 jai r FEE gMOUNT DUE AMOUNT RITTED EMDK RECEIVED BY DATE PERMIT NO, INFO I