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APPLICATION FOR PERMIT SAN JOAQUIN.,LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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.r`,— ' Job Address City Lot Size *,, ! PM Owner's Name a4 7 i0 Address 7, (�,/o ►pel e ; �+. Phone I Contractor L Address License �Phone TYPE OF WELL/PUMP: NEW WELL WEIL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ f 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES DISPOSAL FLD. PROP. LINE ag: 47 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial !❑ Open Bottom ❑ Manteca Dia. of Well Excavation�;L Dia. of Well Casing n Domestic/Private Gravel Pack ❑ Tracy Type of CasingXkIZ Specifications 5;c"l /9,e>7—,Domestic/ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout S&C, Elulrrigation --Approx. Depth. ❑ Eastern Surface Seal Installed by .512 n Repair Work Done OType of Pump Zid H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is I. available within 200 feet.) Installation will serve: Residence '_ Commercial Other s .Number of living units: Number of bedrooms Character of of soil to a depth of 3 feet: ! Water table depth ) SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments P`KG, TREATMENT PLT ❑3 I Method of Disposal i Distance to nearest: Well Foundation Property Line j. f 4 LEACHING-101F ❑ No. & Length of lines I Total length/size r FILTER BED ---El El Distance to nearest: Well Foundation . Property Line ) SEEPAGE PITS-----[5 Depth 1 Size Number f ? SUMPS! ❑. Distance to nearest: V1 ell Foundation Property Line � DISPOSAL PONDS ❑ P s ¢ t I•hereby certify that I fiaveptepa�ed-this application an8`that the wofk w'ill"be4done in accordance with San Joaquin county uFdihances;statelaws,'and` rules and regulations,df the,'San Joaquin Local Health District:,, ">. _z%,"I `� �.3 t : Home owner or licensed agent's signature certifies the following: "I certify that 4n 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 compensaticri'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 eriiploy persons subject to warkman's compensa- tion laws of California." k The applicant must call for all required inspections. Complete drawing on reverse side. Signed X # Sly i Title: Date: f . t. FOR DEPARTMENT USE ONLY Application Accepted by I Date Area Pit or Grout c inspection-by DataOPA�Final Inspection on by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% 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 K RECEIVED BY DATE PERMIT`NO. EH93-241REV.t/E91 7�^7$ EH 7428 �S a q F