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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 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 7y 7a-hu)Z7, City Ca - Lot Size / PM ( ? le a A ��C Address I / J F- S� ��+�� Phone � Owner's Name - C contractor ` A Address b License No Phone TYPE OF WELL/PUMP: MEW WELL - WELL REPLACEMENT ❑ r DESTRUCTION_❑- „ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0' DISTANCE TO NEAREST: SEPTIC TANK 106.-4- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca t Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ i'1 Public 1 F1 Other ❑ Oelta Depth of Grout Seal '/ rf Type 9f Groutt�r�ktl-A- j ._. I I Irrigation !$� It.Approx. Depth I ] Eastern Surface Seal Installed by ct Repair Work Done ❑ Type of Pump H.P.s State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material l8elow 50') a,. TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is 73— available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: _ - Water table depth SEPTIC TANK ❑ Type/Mfg — Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( 1 Depth Size _ Number SUMPS ❑ 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 shalt not employ any person in such manner as tD 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 applicant must call for all required inspections. Complete drawing on reverse /side. e� Signed�X- -�1 �A`L`h, _ Title:��r+.��/ Y /��25. - - -- Date: � [l FOR DEPARTMENT USE ONLY tt��77 Application Accepted by Date Area - iJ Pit Grout Inspection b Date Final inspection by Date 114141, M "r 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE: AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO (� CASH r.EH1324 IREV,i/x t0 r� �/1�• / 7/ '� 7 EH 14-28