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Se x- A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA k Telephone (209) 466-6781 ( PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NO / (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. '� Job Addres r' Q270 City t Size PM Owner's Name /!17` — Address Phone t Contractor Q-c-x.) AJ jef Z_� Address license No. Phone _ f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 'C} �J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ a— DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ;� N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing x l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' " Specifications 1`7 Public Ll Other { C1 Delta Depth of Grout Seal -Type of Grout r � i I I irrigation _..Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material {top 501 . Oa 1t� Depth Filler Material (Below 50 t TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION I I. DESTRUCTIO (No septic system permitted it public sewer is available within 200 feet. M t � � ' J Installation will serve: Residence Commercial_ 'Other $ t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth y SEPTIC TANK ❑ Type/Mfg CaPacitYNo.. Compartments PKG. TREATMENT PLT. Ll Disposal"- - Oistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS , y•tl Distance to nearest: 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 Califatnia."Gontractor:s 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." ' The applican t call for all required ins ctions. Co late drawing on reverse side. Signed X a Title: Date: _ FORfPEPARTMENT USE ONLY ^� Application Accepted by Date �"o~�^� Ara } q Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&%S Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 C a FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED [3Y DATE PERMIT-NO. INFO A /^ f� q C ♦ EH73-241REV..iiHSY -m rl �V �L-�D� 7- d •EH 14-26