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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 City haw Lat Size PM Owner's Name „ IAv.P4vs &1<4r &"d Address ��L C�0!! - Phone Contractor �,C z f rJli�i 45A111--Address License iVo.�?^� Phon 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LlDESTRUCTION 71PUMP INSTALLATION ❑ SYSTEM"REPAIR 1 .' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i { ❑ Industrial "`k 171Open Bottom_ ❑ Manteca Dia. of Well Excavation Dia.,of Well Casing ❑ Domestic/Private ❑ Gravel Pack❑ Tracy Type of Casing Specifications M Public i ❑ Other ❑ Delta Depth of Grout SealTypo of Grout I I } Irrigation --Approxi Depth I I Eastern Surface Seal Installed by F _ Repair Work Done ❑ Type of Pump H.P. State'Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 r Depth Filler Material !Below 50'1 p TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITIO DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other { Number of living units: _/_ Number of bedrooms .405-,..-.___._..-- Character of soil to a depth of 3 feet: Water table depth (j SEPTIC TANK ❑ Type/Mfg Capacity „ _No_,_Compartments PKG. TREATftilIIENT PLT. ❑ Method of Disposal _ Distance!to nearest: Well Foundation, Property Line -F. - .. t x u r i` LEACHING LINE Qr No. & Length of lines f' �� , - Total length/size FILTER BED /❑_ Distance'to nearest: Well�24S FoundationR�JrSI Property_Line' SEEPAGE PITS 11 Depth r Size _- Numbe"r.' "+ SUMPS CI Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ s \� r `" 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 Di$trict. i : j Home owner or licensed agent's signature certifies the following: "I certify that in the perfotmatice 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 Califorhia." 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." r The applicant must call all quired insl2ections. Complete drawing on reverse sides r(/ �y Signed X t:Title:! r Date: +y/ F DEPA ENT USE ONLY Application Accepted by Date/ ZArRa �., Pit or Grout Inspection by Date Final Inspection by Data�a Additional Comments: ` 1 El Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca, a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton`Ave., P.O. Bax 2009, Stk.,,CA 95.201 ` FEE AMOUNT DUE AMOUNT REMITTED Ck 'RECEIVED BY DATE PERMIT'NO. INFO C CASH ..�. t,EH 13-24 1REV.I K 57 EH 1429 QS