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y S%w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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/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. / �/ Job Address q0S MAin S��E2T City C-17-.13/or— _ Lot Size PM Owner's NameUj,,s- V � Pha/�aU Address f��, � 7&s/Ph .._^_ 2 _ _-_ fone Contractor AddressZ23 �111r License No. y`�� 7b Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR CI OTHER CA SD'/ t�Trin DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES :?D __— DISPOSAL FLD. PROP. LINE FOUNDATION Zy AGRICULTURE WELL _ OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation-� _ Dia. of Well Casing [X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing NR Specifications � 1 I'1 Public 04 Other f 1 Delta Depth of Grout Seal __11—S—' ----- Type of Grout Irrigation -is/Approx. Depth r4 Eastern Surface Seal Installed by Repair Work Done tJ Type of Pump H.P. State Work Done _ Well Destruction [7 Well Diameter _- Sealing Material (top 50') Depth _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I INo 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. n Method of Disposal Distance to nearest: Well .___. foundation _ .-_. _ _-. Property Line LEACHING LINE [1 No. & Length of lines _—_ ._.-. Total length/size FILTER BED CI Distance to nearest: Well Foundation .._-_ Property Line SEEPAGE PITS I I Depth V Size _ _ _ Number SUMPS 11 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1) 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 compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ` Signed X_ ti �' / Title: P/aj 'I'D/D S7' Date: FO DEPARTMENT USE ONLY r Application Accepted by �-�-,4 &`( Date G/(i`t�a Area or Grout Inspection by Date Final Inspection by Date Additional Comments: 11 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO . EH13-21(REV.iEH 14 26 1 ' A-Al c v- w-1 C f