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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 7 YEAR FROM DATE ISSUED (Complete inTriplicate) 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 Local i made 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 - Health District. `` � + ,6 ` � Job Address J t'} y Lot Size I Imo,, PM Cit Owner's Name --h614 c d wo AddressR r " �L� Phone J _ � I Contractor Address License No, %OWPhont � o�i> 1 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑.- DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL x PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open_Bottom__,CJ Manteca.�,,,,,,,,,�Dia. of Weli_Excavation Dia. of Wel! Casing ❑ Domestic/Private CJ Gravel Pack 0_Tracy Type of Casing Specifications .�. ❑ Public ❑ Other ❑ Delta- °'�al 'De ,th of Grout Seal I . ,P, Type of Grout ❑ Irrigation ��Approx. Depth El-Eastern Surface?Seal Inttalled by Repair Work Done ❑ Type of Pump State Work Done E r Well Destruction ❑ Well Diameter 'Sealing Material (top 50') Depth L—Filler;Material_IBelow_50'1 -----•k._-_ _ i !' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO,N. DESTRUCTION ❑ (No septic,system permitted if public sewer is w available within 200 feet.) t. Installation will serve: Residence i >?r:4 Commercial Other M1 i t t Number of living units: Number of bedrooms_ Character of soil.to a depth of 3 feet: f - Water t ble depth f SEPTIC TANK ❑ Type/Mfg y "Capacity ' No. Compartments PKG. TREATMENT PLT. O yyy Ir Method bf Disposal t, 1 Distance. b nearest: Weil. "Fou datioh` `- Property Line f LEACHING LINE #:=.[D No:& Length of lines t Total length/size 4 FILTER BED ❑ Distance to nearest`'!-'Well Foundation Property Line SEEPAGE PITS ❑ Depth Size " Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t �--i' W hereby certify that I have prepared this applicationand 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. tg _ 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 lawsf 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 em to - tion laws Of Californi e ` " P Y PeTsonssuar7ject to workman's compensa The applicant mus c for` inspec ns. Complete drawing on reverse side. = T- Signed X Title: d Date: # ` � ° i R DEPARTMENT USE ONLY Q� Application Accepted by 1l h k Oate I "� l AreaF Pit or Grout Inspection by Date Final-Inspection by ate y Additional Comments: , 4 ❑ Stk 466-6761 ❑'Lodi 1 1 ❑ Manteca 823-7104 ❑J Tracy '835-6385" !Applicant- Return all copies to: Environmental Health Permit/Services 1601..E. Hazeltbn Aver, P.O', Box 2009, Stk., CA 95201FEE � INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED-BY y1 DATE PERMI7'NO. - + EH 13.24(HEV,I/n s) y EH 1426 nr