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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 � �� (Complete in Triplicate) L 19 I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the'Dwoi ws+ iv lion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rule (r oaquin Local Health District. Job Address .— city y Lot Size PM � P 1 / � Owner's Namte�, /��,,�_ Address �cg_9C1 Lc/,�, 1' Phone Contractor 'v ! Address �T "�. f License No/6 X-3 7 Phone 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ®"- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 137ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private- ❑-Gravel Pack--,- - -.❑ Tracy-- -Type of Gasing= = --- Specifications f`i Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _--App(ox. De h I ) Eastern Surface Seal Installed by j Repair Work Done Car T r p Type of Pump"' H.P. State Work Done Well Destruction ❑ Wel! Diameter Sealing Material (top 50') I Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION i.) REPAIR/ADDITION l I DESTRUCTION i I (No sep ' ystem permitted if public sewer is a le within 200 feet.) i Installation will serve: Residence Commercial_ Other Number of living units: N bar of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: I Foundation Property Line LEACHING LINE Cl No. & Len of lines Total length/size FILTER BED ❑ Dista to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth il Size Number SUMPS ❑ Distance to neatest: Well Fou ation Property Line DISPOSAL PONDS p 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 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 shaI 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 k 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." t The applicant u call f r all re uir inspection Complete drawing on "' Signed X J-Title: 77;;. Date: 6-7- rJ o a 47 ,DEPA TMENT,USE ONLY Application Accepted by01, Date Arar QC Pit or Grout inspection by Date - Final Inspection by pa ! Additional Comments: i i ❑ Stk 466-6781 0 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 AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. + EH1 3-241REV,tins) -3s"311 '7—,g E3e—t r EH 14-26 Q 1!