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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {2091 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. 1� F � Job Address C tot Size /V® a, PM Owner's Name Address L ASq Phone Contractor Address - -License No_�W2:2- � Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT--O DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS ❑ Industria! >Ge tom ❑ M eco pia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Privateck racy Type of Casing Specifications F] Public ❑ Delta Depth of Grout Seal Type of Grout I i Irrigationepth l 1 Eastern Surface Seal Installed byRepair Work Donep H.P. State Work Done Well Destruction er Sealing Material (top 50') Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION,* DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) I / Installation will serve: Residence__X__ Commercial— OtherGa�er- Number of living units: --l— Number of bedrooms 0 (y,, Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK C] Type/Mfg _ _ �Jl�,:[� Capacity_ /�� No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well S,�� Foundation___.._511Z Property Line 19.1-1- LEACHING LINE Ir'No. & Length of lines S Total length/size p FILTER BED ❑ Distance to nearest: Well -�Q;�f Foundation 7/Q/� Property'Line 11Z/ SEEPAGE PITS I 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 wilt-be done in accordance with San Joaquin county ordinances, state laws, and 1 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."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." I I - I The applicant must all for all required inspections. Complete drawing on reyerse,side._..1 Signed X Title: '—2- 9 8 9 c bate: FOR DEPARTM NT USE ONLY Application Accepted by Date 3 r Area ,2 3 _ Pit or Grout Inspection by Date Final Inspection by G1, Data _ Additionaf-Coitirnents=_ -44- - T - ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 1-7/3 DATE PERMIT'NO. +.EH 13-26 TREY,t/R 51 6 qEH t4-29 51 -i S7