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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 •7'�" PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3-5'1 v u/ V ev J4V?-City J/_-4+e?d1 Lot Size PM pwner's Name. t Address —23 4 eu. D(A rq— Phone a F- .N. y_ . Address �, Contractor License No. Phone TYPEOFWELL/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 # 4.14TENDED USE TYPE OF WELL PRO13LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial : ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 171 Other ( f Delta Depth of Grout Seal Type of Grout I I Irrigation i ----Approx. Depth I 1 Eastern - Surface Seal Installed by i Repair Work Done i ❑ Type of Pump H.P. State Work Done ( .rJ Well Destruction ❑ Well Diameter ' Sealing Material Itop 50'1 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION la =REPAIR/ADDITIOWIs]_;;DESTRUCTIOf No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial w Other ` /Number of living units: Number of bedrooms 0 .a Character of soil to a depth of 3 feet: tr _ Water table depth k SEPTIC TANK ❑ T e/Mf YP g Capacity No. Compartments r PKG. TREATMENT PLT. ❑ � Method of Disposal } Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines F Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 De1i . pth Size ~ Number SUMPS Cl Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS i ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Jbaquin county ordinances, state laws, and rules and regulations'of the San Joaquin Local Health District. ; 1 , N 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."Cofitractors hiring or sub-contracting signature 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." 1.. The appli ant must call for all required inspections: Complete drawing on-reverse side. Signed X Title: Date: -- FOR DEPARTMENT USE ONLY N `f t {J Application Accepted by Date In � Z~ Area 1l` Date Pit or Grout Inspection by Data Final Inspection by } R Additional Comments: Cl 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 �r T\ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ] / CrASH1 2{ EH14-28tpEV.iin51 .a.�� J`+ /�/1 V M.'�r\ �� ,� ✓✓