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w. APPLICATION FOR PERMIT f ` " SAN J_OAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. �r+ -y-- Job Address (o�SS La i�I�/�/y ! .. City Lot Size A. 4LAe- PM Owner's Name 77 Contractor Phone 5; Contractor Address License No. Phone TYPE OF WELL/PUMP: w NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOON�� SYSTEM REPAIR ❑ OTHEP ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ZS?�' PROP. LINE -- O-_ FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑-MRanteca Dia.-of Well Excavation Dia. of Well Casing (Domestic/Private 20Gravel Pack ❑:Tracy Type of Casng �� Specifications+:- i f_1 Public ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout I I Irrigation ZW_Approx. Depth I I Eastern .1V ;.Surface Seal Installed by Repair Work Done ❑ Type of Pump TU f H.P' - State Work-,Done ' ' Well'Destruction ❑ Well Diameter t Sealing Material (top 50') I tj i Depth Filler_MAerial (Below 50') rQ� r TYPE OF SEPTIC WORK: NEW INSTA 1-1. •REPAIR/ADIPITION-F-1 ••ESTRUC--TION I I (No septic system permitted if public sewer is V t available within 200 feet.) y installation will serve: Residence ',Commercial_ Other er - FNumber of living units: - - ``Number of bedrooms t �. Character of soil to:a- th 6f..3 feet: ' a er table epth 'r SEPTIC TANK f 0' Type/Mfg cap No. Compartments PKG. TREATMENT PET.El ~� Method of Disposal + }� Distance to nearest: = ndation Property Line .._ t 'LEACHING LINE ❑f-No."& L 'of lines° _ Total length/size FILTER BED Q � ance•to nearest:- --Well `y 'Foundw "-'—"„-""'Property Li e� r f M SEEPAGE PITS I I Depth Size _ umber SUMPS ❑ Distance to nearest: WellFoundation a Line DISPOSAL PONDS El _I.hereby.certify_that..l have-prepared-this,a_pplication 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. 1 Home owner or licensed agent's signature certifies the following: 'Tcertify 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'$compensa- tion laws of California." , The applicant o all requ ctions. Complete drawing on r er a. Signed X Title: Date: FOR DEPARTMENT USE ONLY � F Application Accepted by r Date �67� e U Area 1 Pit or Grout Inspection bys' DatFinal Inspection by -��r75X["/`� Date :� d Additional Comments: 1 77 11Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I � INFO AMOUNT DUE AMOUNT REMITT<D CASH CK 41 RfCEIVEp i3Y DATE PERMIT'No. EH13-241REV.r/n5i EH 14-28 666 / i