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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZE T ON AVE., STOCKTON, CA jfil J 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address /38 70 e, I+A@.N e y City 1,1Ds Lot Size PM Address Owner's Name V3070 FT N Phone -3- � Contractor a Q-+V•` Address :741 ` Jk— License No.-MPhone33 ! A 130 , TYPE OF WELL/PUMP: NEW WELL'< WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-❑ OTHER ❑ l t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ��" r� DISPOSAL FLD.�_T_ PROP. LINE FOUNDATION °� AGRICULTURE WELL _ OTHER WELL� � PITS/SUMPS Lirl.? -71 INTENDED USE € TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION t 5-1 ❑ Industrial { ` pen Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pack ❑YTracy. Type-of.,Casing 542" Specifications 10q dL � M Public ❑ Other, _ F1.Delta Depth of Grout Seal Type of Grout 1 I I Irrigation j a��f.Approx. Depth I ]`Eastern ',,Surface Seal Installed by Ttill.4 - p 3 Repair Work Done © Type of Pump, t H.P. State Work Done_I Well Destruction ❑ well-Diameter I Sealing Material (top 501 Depth f Filler Material (Below 50') '} I A TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIWADDITION l I DESTRUCTION l I (No septic system permitted it public sewer is- available s available within 200 feet.) CP Installation will serve: Residence Commercial_ Other I Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feel: r Water table depth Cf SEPTIC TANK ❑ Type/Mfg t Capacity No. Corripartments PKG. TREATMENT PLT. EI Method of Disposal Distance to near Well Foundati n Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size, Yom' FILTER SED ? ❑ Distance to nearest: W Foundation Property Line SEEPAGE PITS l 1 Depth j Size Number i SUMPS Cl Distance to nears Well Foundation Property Line 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." y +. The applic st call for all re red.in n . Complete drawing on reverse side. / .Signed le: _ Date: ` 4 FOR DEPARTMENT USE ONLY Application Accepted by r Date ` Area O x_: Pit o Grot Inspection by- ate"' final"Inspec"tion fly J "`" ""` Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .J ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE I NFO A DUNT DUE t AMOUNT REMITTED CK CASH RECEIVED BY DATE PER C7�7 t EN 1324]HEV.s/x5f 0..�� EH to-29