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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 heieby 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. C1 Job Address City�� Lot Size PM Owner's Name 10 Il r!�' 1 _C`Ce" Address 7.;Z1 Z1 5y, /U/7 S��N Phone 10— 37,.<c Contractor Address X U7 ��1: a_1kcee No.._ayJ$�+� Phone ris �J3d TYPE OF WELL/PUMP: NEW WELLN WELL REPLACEMENT ❑ ^DESTI*JCTIQN`[] PUMP INSTALLATION El SYSTEM REPAIR 171001ER ❑ ty l DISTANCE TO NEAREST: SEPTIC TANK fob SEWER LINES DISPOSAL FLD.J{X)__—PROP. LINE 7 FOUNDATION AGRICULTURE WELL .� - OTHER,WELL=,� PITS/SUMPSsL Pj INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial N jDpen Bottom ❑ an— tl 1 Dia. of Well Excavation J,3 Dia. of Well Casing 20omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications X074 [-I Public Cl Other ll Delta Depth of Grout Seal U T e of Grout 1 . I Irrigation --Approx. Depth 1 I Eastern Surface Seal Installed by s _ Repair Work Done ❑ Type of Pump H.P, State Work Dori, _ Well Destruction ❑ Well Diame Sealing Material (top 5071 Dept Filler Material (Below 50').'— TYPE 0'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic,system-permi'sted if public sewer is available within 200 feet.) r Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms . Character of soil to a depth of 3 feet: k Water table depth rn SEPTIC TANK ❑ Type/Mfg apacity- No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest: WellZ Foundation Property Line (� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest-,/W ell Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to ne rest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this 4pplication 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 performar%ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif nia." i The applicant equed inspe !Complete drawing on reverse side. Signed Title: Date: FORD ARTMEeeN__T USE ONLY Application Accepted by Date Area r Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 1( ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�'NNO. +.EH 13.24 IFIE 1/K5) _q_O. �i ^1 'a(s' ;f ` EH 14-28 r J