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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 r (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 1'� � /\yC`_'-[ ! /L`l�zlc y��.(I�L. City X1 A f' Lot Size r'r �. PM Owner's Name ! I i.al _C I` _ Address _/_� :SC)�4k K Q to -:5 Phone Contractor c_ZA4It h,& Address j'* �s ('j�j- r. t�l icense Nock 32 �Phone TYPE OF WELL/PUMP: NEW WELL° WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fl_ PROP. LINE- FOUNDATION INE-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S fr ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 191�pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,{P_ Specifications 1-1 Public f 1 Other 171 Delta Depth of Grout Seal Type f Gwut I IrrigationS_ Z_Approx. Depth l l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump -b H.P._7 State Work Done_ p Well Destruction ❑ Well Diameter Sealing Material (top 501 f n Depth Fiiler'Material (Below 50') t^1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t I DESTRUCTION I I fNo septic system permittedif public sewer is 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 C1 No. &.Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑- \\\ 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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. Signed XC e �nA � �`,..,— Title:', "' r Date: ` FOR DEPARTMENT USE ONLY Application Accepted by Date"2- Area ) Pit or Grout Inspection y tZ7 Date Final Inspection byDate ( Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE pERM1T'NO. +.EH 13.24IREV.i/n5) EH 14-26 a t <=> 3