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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA t Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATEASSUED N i! (Complete in Triplicate) i 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 mi%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 i ✓ �' • 1,x,7, , = �°� City Lot Size Owner's Name ,, 1J n ddress Phone I Contractor's Name 1 ss No- Phonel--'3, TYPE OF WELL/PUMP: NEIN WELL El -fWELL FfEPONCAAENT IT DESTRUCTION LJi� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. v 1 SEWER LINES DISPOSAL FLO. PROP. LINE ) I�! FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS Ili INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑i Industrial ❑ Open Bottom ❑ Manteca) Dia. of Well Excavation Dia. of Well Casing ❑•Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑.Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation :Approx. Depth El'Eastern Surface Seal Installed by Re air Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 5b') �I Depth Filler.Mate?iai (Be-low 50'i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted'if public sewer is "> available within 200 feet.) J , Installation will serve: Residence Commercial, Other, } Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I '* Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments >r PKG. TREATMENT PLT. ❑ ' 1 Method of.Disposal I Distance to nearest: `Well Foundation - — Property Line t Al -r— LEi4CHING LINE 415'-,No. & Length of lines Tolal length/size FI TER BED ❑ Distance to nearest: Well Foundation ._. __ Property Line Q fg SEEPAGE PITS kL Depth Size �J ,,Number SUMPS ❑ Distance to nearest: Well Foundation T _ Property Line.-Zr� 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 shall not erri Ioy 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- tidn laws of California." The applicant must ca fo required in tions. Complete rowing on reverse side. rZ 9 Signed Title: Uate: FOR DEPARTMENT USE ONLY Application Accepted by Date f A a 1 ql! Pit or Grout Inspection by Date ' Final Inspection by Date'; ap Additional Comments: I Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 x' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4FEE AMOUNT DUE AMOUNT REMITTED CASH CK It RECEIVED BY DATE PERMIT"NO• + EH 1,11-:9 V.10la31 JA S,!