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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 486-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health D;strir.t. Job Address 50 �• `�`z .._ _ r City Lot Size_._._ PM Owner'sName'rAdds v 1J _ r w� Phone ---- Contrac Address ��/ J License No. Phone TYPE OF WELL!PUMP: NEW WELL C WELL REPLACEMENT ;7 DESTRUCTION C PUMP INSTALLATION G SYSTEM REPAIR .0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.__. _ PROP. LINE (' FOUNDATION__._ '__— AGRICULTURE WELL -__ OTHER WELL _ _PITS/SUMPS / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , O Industrial ❑ Open Bottom C Manteca .Dia. of Well Excavation Dia. of Well Casing C Domestic/Private ❑ Gravel Pack l ' Tracy Type of Casing __ Specifications / 1"1 Public r7 Other Li Delta Depth of Grout Seal _ Type of Grout I I litigation — Approx. Depth I I Eastern Sufface Seal Installed by_-______-__. Repair Work Done 11 Type of Pump _ ___ H.P. —__ -_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 - Depth __ ' r Material IBelow 501 1 YPE OF SEPTIC WORK: 'NEW INSTALLATION l 1 EPAI DDITIO DESTRUCTION ; I (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: 'Residence Commercial A- OtherAg�yypp Number of living units: ` _. Number of edrooms4' A i r Character of soil to a depth of 3 Net: Water table depth SEPTIC TANK J Type/Mfg r Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well __. Foundation Property Line LEACHING LINE O No. & Length of lines _ _____ Total length/size___ ._ FILTER BED 1l Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS Depth Size _�_tNumber SUMPS Li Distance to nearest: Well 1�! Foundation� Property Line •- - DISPOSAL PONDS - --L7 _ 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, arid_- / 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 perrtvt 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 tho performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. tion laws of California." The applican ust call for qtr' d inspections. Complete drawing on reverse srd Signed X - Title: --., � Date:0,o001 A4 FOR DEP RTMENT USE ONLY l Application Accepted by-� _ Date_ '�, ._.._ .� Area .jild Grout Inspection byeE`�� ate ' Y� Final Inspection by Date%� Additional Comments: ❑ Stk 466-6781 G Lodi 369-3621 L Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Reiurn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave- P.O. Boz 2009, Silk., CA 95201 FEE ' AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO 4V of CASH rf EH 13-24(FEV.":K - .• r EH 14 28