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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—I ON AVE., STOCKTON, CA Telephone (209) 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. p�g� }�/{ 1 Job Address f(llyw,o gl.fii City t `At 7 c-C,4 Lot Size PM Owner's Name.bcPf61 &L4 J04001IIIt&. Address /1411 .E. >S.;IitV 12 U 144WF44 Phone z3'310 1 Contractor &K>Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ c DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL " ` PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrialpen Bottom ._ anlpf'M teca Dia. of Well Excavation - / Dia.`of Well Casing— M1 , ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casings! Specifications Z❑ P c C1 Other ❑ Delta I -Depth of Grout Seal Type of Grout rrigation / -C- Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 00 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTA TION ❑ REPAIR/ADDITION ❑ DESTRU ION ❑ (No septic system permitted if public sewer is available within 2pD feet.} i Installation will serve: Residence_ Commer ' _ 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 fIx PKG. TREATMENT PLT. ❑ _- Method of Disposal Distance to nearest: Well Foundatio Property Line LEACHING LINE ❑ No. & Length of lines lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation party Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r 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, an 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 call for all required i spections. Complete drawing on reverse sine. Signed Title,7Q fww a�c-f��/t., Date: � Is FOR DEPARTMENT USE ONLY ^-1 Application Accepted b Date —� `� Area _ Pit or Grout Inspection by Date Final Inspection by _ Date 033Y-97 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M 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 RECEIVED BY DATE PERMIT`NO. + EH 24(REV.i/asl W EH 14-28 A�