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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'-HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA f Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR4ROM DATE ISSUED w (Complete in Triplicate) F: 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 t made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 far well pump and the Rules and Regulations of the San Joaquin R Local Health District. .P .. Job Address BBQ fi` 'pr' s — � — City ! Lot Size_ . o ete -a- PM Owner's Name Address Phone i� Contractor d!r' Address N. License No.AV4J Phone E J`jTY,PE,OF WELL/PUMP: NEW WELL 1g WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK _ ISO o SEWER LINES DISPOSAL FLD. 160 PROP. LINE _/W— ; FOUNDATION AGRICULTURE WELL 4`99) OTHER WELL PITS/SUMPS t� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LJOpen Bottom L3Manteca Dia: of Well Excavation „ f< Dia. of Well Casirfg Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications 140 t ❑ Delta Depth of Grout Seal �S�i Type of Grout ❑ Public ❑ Other ' 1 El Irrigation ---Approx. Depth E3 Eastern Surface 5eal.,lnstalled by Repair Work Done ❑ Type of Pump H.P.' Y State Work Done '1 Well Destruction ❑ Well Diameter Sealing.Material (top:50') : "�•_ ,;_� ( -*, 4 .-..�...,�,.-•,•.--••�•--�-Depth---�-""^�"�."�...»'......,,.Fillei M`aterial'{Below'SO'}`"".�...._.-,."�..':`'°'_.."r.'�.---w-.. j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ .(No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Com1mercial_ Other i x1 Number of living units: Number of bedrooms - A*Character of soil to a depth of 3 feet: # � '+ Water table depth �} SEPTIC TANK ElType/Mfg Capacity ve 3-T ,y�No. Compartments ` PKG. TREATMENT PLT. ❑ : �t Method of Disposal 5i Distance to nearest: Well Foundation Property Line i a l t ` LEACHING LINE LlNo. & Length o£lines Total length/size ' FILTER SED ❑ Distance to nearest: Well Foundon Property Line ¢ tF Number f SEEPAGE PITS ❑ Depth Size � r SUMPS [71Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l k I hereby certify that I have prepared this application and that the work willdie_done"infaccordance with San'Joaquin county ordinances, state laws, and rules and regulations of the'San Joaquin Local`Health District. 'fy 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,1 shall empty persons subject to workman's compensa- tion laws of California." ' The applicant must call for al squired inspections. Complete drawing on reverse side. Signed ......_ Tits,,_."� - - Date: xh-e _ FOR DEPARTMENT'USE'ONLY Application Accepted by Date 3 Area Pit or Grout Inspection by Date Final Inspection by Date i y Additional Comments: ❑ 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 85201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. INFO +EH 13-241REV.t/95) � 7 0 - 1�kl—cP-7EZ_ 607-104C EH 14-28