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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (Complete in Triplicate) I Application is hereby made.to-the'San Joaqui&Ubcal Health District for a permit to construct and/or install the work herein described. This application is 1 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. ! i Job Address �ViA Awo kL UT � � ' _ City CLeenq 4Lot Size PM Owner's Name l rt Go. Pe W11 Addressl�f. ''�"' Phone Contractor—. �r_- Address �-'� License No. "+'_ .Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ h o5Sl " I PUMP INSTALLATION.LJ SYSTEM REPAIR LJ [� OTHER T WM4,,,L._. w"'J DISTANCE TO NEAREST: SEPTIC TANK e� .— SEWER LINES DISPOSAL FLD._�V` PROP. LINE �4 t FOUNDATION AGRICULTURE WELL OTHER WELL t+ 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 090'117 Specifications R f f'3 Public % Other TDelta Depth of Grout Seal Q7�'i� Type of Grout _. f �jI Cl r I ,' I i Irrigation Z-Approx. Depth i I Eastern Surface Seal Installed by_ NC N IL-. Repair Work Done ❑ Type of Pump H.H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material Itop 50'I 'rte• i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system.permitted'if public sewer is available within 200 feet.) Installation 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 Irl Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i hereby certify that t 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 Di§trict. 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-,_,J tion laws of California." The applicant call fq1,all required inspe Complete drawing on reverse side. Signed X Title: 5 �( — Date: FoFkDEPARTMENT USE ONLY Application Accepted by Date —� Area / Pit or Grout Inspection by ate Final Inspection by ' Date Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 00 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE D PERMIT NO, J INFO a.EH 13-24(REV.$/115) - EH 1 -28 - _