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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telepl ohe (209) 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . t I. (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 I Local Health District. Job Address — City / Lot Size PM k Owner's Name TA A I Address Phone y Contractor0 Address License Phon_670 r44 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE 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 Jam] 1`7 Public F) Other Cl Delta Depth of Grout Seal Type of Grout _ I k I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by d' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ 1 Well Diameter Sealing Material (top 50') j Depth Filler a elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1, REPAIR ADDITION DESTRUCTION l I INo septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms i xX Character of soil to a depth of 3 Meer. Water table depth SEPTIC TANK ❑ :Type/Mfglj Capacity No. Compartments PKG.'TREATMENT PLT. ❑ .11 j Method of Disposal "Distance to nearest: Well Foundation Property.Line hde LEACHING LINE No. & Length of lines — g7v Total length/size7' FILTER BED ❑ Distance to nearest: Well q��Foundation " !JE Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ ' Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di3trict. 1 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 followi a"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 Califoni .' The applica m call fo 1 re u' ins mplete drawing on rev aid Signed X Title: a Date: n F. I USE ONLY Application Accepted by _ e,tf �� r* •• �t Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: U ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A�{� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I �I FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. INFO CASH a00 � C EH 1241[iE' 00 1/M51 O r -EHH 14-4-29 �'�. y..