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r t I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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/of 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 .___._ 14f, ptki-f- �„ _ City I+ Lot Size d PM Owner's Name C!' Addres,14_2 � -, PhoneryZe_, 7� Contractor.—fal F Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _._DISTANCE TO.NEAREST:-SEPTIC,TANK SEWER LINES DISPOSAL FLD. PROP.,LINE, FOUNDATION AGRICULTURE WELL OTHER'INELLi PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel'Pack ❑ Trac Type of Casing Y YP 9 � Specifications I`l Public Cl 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 Well Destruction Well Diameter SP. State WorkiDone ealing Material-(top 50')' GYS-t I Depth Filler Material /Below 50'1 I f _ i TYPE OF SEPTIC WORK: . NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if publ' sewer is W t t available within 200 feet.) Installation will serve: Residence_ Commercial_ Other J Number of living units: Number of bedrooms '± I, Character of soil to a depth of 3 feet: I ; J " Water table depth SEPTIC TANK ❑ Type/Mfg1I Capacity No. Compartments; PKG. TREATMENT PLT. ❑ } Method of Disposal \w Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ No. & lines of Length t 9 I Tata! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size r # Number DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Loca! Health District. i ) Home owner or licensed agent's signature certifies the folEowing: "I certify that in tha 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 Galifomia."_;Contractors hiring of sub-contracting signature certifies the following: '9 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." n The applicant mu allall requir ins pe ions. Complete drawing on reverse side. t Signed X 66� Title: Date: F R DEPARTMENT USE ONLY # Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Data 1/'Zl�$! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 0<fAanteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. KCASH ♦ CPO EH t3-24(REV,ti 5) f� /\',r EH 1�-29 � ��' V � �// / J i/