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rl APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 1 PERMIT EXPIRES TYEAR FROM DATE ISSUED it (Complete in Triplicate) t 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .1 r Job Address 70oo )F _ City Lot Size PM Owner's Name N Address Phone ••� ; lD Address + �• �✓D]� -767 3Z�5 z ZAP �vb fU5 ContracF License No. Phone TYPE OF WELL/PUMP:- t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION F-1 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 f DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP+ LINE 'FOUNDATION AGRICULTURE WEl'i' - 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 Public Fl Other Cl Delta Depth of Grout Seal Type of Grout. _ I Irrigation _Approx. Depth { I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump .P:, , `State Work Done _ ? Well Destruction ❑ Well Diameter Sealing Material [top 55001 a Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residencex z Commercial _ Other Number of living units: Number of edroo _ r Character of soil to a depth of 3 feet: T '_Water table depth J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l t, Distance tof nearest: Well Foundation Property Line + LEACHING LINENo. & Length of lines �Y ` �-- "-.4� 4 Total length/size 0I>e— 41 K FILTER BED ❑ Distance to nearest: Well Foundation_/D Propertv'Line SEEPAGE PITS i I Depth Size X x Number J Distance to nearest: r t _ _Well _Foundation _ Property Line DISPOSAL PONDS _ ❑ + I hereby certify that I have prepared this application and that the worts will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r i Home owner or licensed agent's signature certifies the following: "f 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,l shall employ persons subject to workman's compensa- tion laws of California." I �% The applicant �tllreq .ed inspections. Complete drawing on reverse side. .� Signed X Title: r • Date` FOR DEPARTMENT USE ONLY Applicati Accepted by Date /` t�J Area or ou Ins ion by DateB Final Inspection by Additional Comments; ❑ 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 INFO AMOUNT DUE ! AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 1 r.EH 13-24(REV.I/n s1 /� a 1 0 EH 14-25 ^l