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i APPLICATION FOR PERMIT ii SAN JOAQU.IN LOCAL HEALTH DISTRICT �I - Ij 1601 E. HAZEL I ON AVE., STOCKTON, CA j Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 koaquin County Ordinance No.549 for sewage or No.,1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address Q.0 Q �/Lrir,�C; City Lot Size PM ��I s _� � 0 -Owner's Name dress d `Phone � � 1 i�� Contractor Q.�(��(y Address 4�� ' "' -'- L'+cense No.A 1 Phone TYPE OF WELL/PUMP: i!. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 13 SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES4. DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL 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 El Public ❑ Other ❑ Delta -Depth-of-Grout-Seal Type of Grout ❑ Irrigation '_�4pprox. DAW ❑ Eastern Surface Seal Installed by Repair Work Done &I Type of Pump er H.P. State Work Done Well Destruction 1-1Well Diameter SealingyMaterial {top 50') ` i I Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW IN ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200,feet.) Installation will serve: Residence Commercial_ Other ' Number of living units: Number of bedrooms i Character of..soil to a depth of 3 feet: Water table depth SEPTIC TANK' ❑ ;)Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 'I �•, Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines *- t Total length/size FILTER BED ❑ Distance to nearest:.Well Foundation Property Line { SEEPAGE PITS ❑'i, Depth i Size " '""""�" 'J Number II ? SUMPS ❑ .I Distance to nearest: Well Foundation Property Line_ ! I DISPOSAL PONDS ❑ ::. :.-.�-.� - I hereby certify that I have piepared this application and that the work will be done:in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District, , s Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which tFiis 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,I shall employ persons subject to workman's compensa- tion laws of Car rnia." II The applican qt c for all requir d 1 ions. Comp to drawing on reverse side. I. Signed Title: T�]%1 Date: i RDEPARTMENT SE ONLYt � I� !N z Application Accepted by Date` Ares e r �, Pit or Groutlnspection by Date F' al Inspection by Da; ' Additional Comments: IIS ' ❑ Stk 466-6751 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 - Lt Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009, Stk.,,ePfJ5201 {_^ FEE AMOUNT DUE AMOUNT REMITTED ASW RECEIVED BY DATE 4 PERMIT NO3' INFO r r +EH 13-241REV.i/a 6) EH 1126 "