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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �1 Telephone (209) 466-6781 1 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 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 Address / © C City Lot Size PM, Owner's Name � ��e __ 'Address ///�✓ �` 7 M1 5 - _ Phone Contractor f� Address`TLF Y1� G. License No. Phone / • a TYPE OF WELL/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' I e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 13-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j ['I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 11 Well Diameter.. Sealing Material Itop 501 } 'Depth- { " ..l Filler Materia! IBelow 501 TYPE OF•SEPTIC WORK: -NEW INSTALLATION'y REPAIR/ADDITION { I DESTRUCTION t I (No septic system permitted if public sewer is y available within 200 feet.) Installation will serve: Residence Commercial_'"'Other - Number`of living units: Number R bedroo §' . Character of soil to a depth of 3 feet: ` < Water table depth SEPTIC TANK P9 Type/Mfg .�i Capacity � � No. Compartments PKGTREATMENT PLT. ❑` Method of Disposal Distanceto nearest: Well/1964 « Foundation Property Line �D LEACHING LINE No. & Length of lines r� tal length/size S FILTER BED ❑ Distance to nearest: We(I ems: Foundation Property Line d z i SEEPAGE PITS l I Depth �� Size 0Z� 1,97 ✓ /2 Number SUMPS Distance to nearest: WellASO if Foundation Property Line DISPOSAL PONDS ❑ t I hereby certify that t 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: "! certify that in the performance of the work for which this permit is issued, I shalt 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 California." The applin st r re i ctions. o late drawing on reverse side. Signed X r Title: / Date: POR DEPARTMENT USE ONLY 9dilional icatian Accepted by Date R Z v� Area 1 r I r uy Date Final Inspection by''• Date Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- T 835-6385 Applicant - Return all copies to: Environmental Heath Per ' /S ices -11601 E. Haz on Ave., P.O. Box 2009, Stk., CA 95201.. I INFO FEE AMOUNT-DUEAMOUNT REMITTED CASH RECEIVE BY DATE PERMIT-NO. ♦ EH 13-24(REV.I/K51 `�]� fir'f /T ' �] 245� ' EH 14-26 - { V � C/