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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 e 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. L p �j� , t Job Address E/7 � �`�t/�ti r` c`v City ��Q—� Lot Size PM �� p Pr� Phone — Q�Q Owner's Name l.t/L _ a��C- Address Contractor Address A&4cense No. 6 f-3 Phone_ TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK IM" SEWER LINES DISPOSAL FLD.�+-PROP. LINE I FOUNDATION: AGRICULTURE WELL OTHER WELL_,!3__' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r ID Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ ��, Dia. of Well Casing Domestic/Private �I Gravel Pack Tracy Type of Casing / Sp ifications i F1 Public Cl Other F1 Delta Depth of Grout Seal �6 Type of Grout t I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by �,16ZZI L Repair Work Done ❑ Type of Pump I H,P. State Work Done Well Destruction ❑ Well Diameter') Sealing Material (top 501 , if Depth Ia o/ Filler Material ;Below 50') — I° TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DLSTRUCTION { I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth E 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 I I Depth Size _ Number SUMPS Ll 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 Di3trict. 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 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 applicaZV1.,fd(kdAV ust call for all requ- inspections. Complete drawing on rse side. Signed XTitle: Date: /07 FOR DEPART NT USE ONLY Application Accepted by Date Area (412 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: No amwa 4k/ 04K4t*&"*0,MXr. r 7LJ tom. N /1�(At1.T ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 C1 Tracy 835-5365 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton_ Ave., P.O. Box 2009, Stk., CA 95201 73- 12 2 Z-4 I n"e-W 40 'TU7'_-/b Sd��[�"� �'' G/z-� fo2rJ 3-p -73, C! FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'N10. ' INFO CASH ♦.EH 11�-2tS 3-2�IREV.i/n 51 EH _7 N M�L 1 i �