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APPLICATION FOR PERMIT UZ' 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 herebrii ade 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 E 9,5760411!�iCa City �fEst Lot Size PM Owner's Name A At/At Address� Phone Contracto10-SION AddressV90 / 4:& 4 ,gif License No. Phone VA '.� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR'C 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 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done L7 Type of Pump H.P. State Work Done W Well Destruction ❑ Well Diameter Sealing Material Itop 50') t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION DESTRUCTION i 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other n Number of living units: --/— Number of bedrooms ,3! (J Character of soil to a depth of 3 feet: Water table depth -� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments w'PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size f .* FILTER BED Q Distance-to nearest: Well AM,.— Foundation Property Line SEEPAGE PITS )4 Depth _ Size _ Number SUMPS Ll Distance to nearest: Well/ -- Foundation�d_ Property Line !� Y DISPOSAL PONDS ❑ .� 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 J rules and regulations of the San Joaquin Local Health District. �. Horne 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,si ax�rte 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. p Signed X Title: date: FOR DEPARTMENT USE ONLY Application Accepted by - Date Area Pit or Grout Inspection by Date Final Inspection by Date 1 Z Additional Comments: 1 G'G ' !�L" 1� ❑ Stk 466-6781 ❑ Lodi -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 CK RECEIVED BYDATE INFO {may CASH PERMI7IUD. t.EH 13-24tREV-1i951 - +D'� EH 14-28 f ` D�