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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 I 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address /4 C 0C- , 1` City I'(`1`I C11 CF4"g Size PM Owner's Name C• "„il-10E2SE,e-,'Address Phone Contractor.�� L I [r�11 Address C License No. ��• Phone e�, �,r< TYPE OF WELL/PUMP: I` NEW WELL.❑.-;� $� WELL REPLACEMENT EI [7)PUMIIP INSTALLATION?❑r ' ii SYSTEM-REPAIR-❑ OTHER ❑ DISTANCE TO NEAREST: SEPT� IC TANK ; SEWER LINES DISPOSAL FLp. PROP. LINE FOUNDATION AGRICULTURE WELL w `t OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ OIL pen Bottom ❑ Manteca I-----Dia-of-Well..Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing I .F 9 Specifications ❑ Public ❑ Other F1Delta Depth of Grout Semal- Type of Grout _. I Irrigation _h`k pprox. Depth . 1,1 Eastern Surface Seal Installed y Repair Work Done El Type�`of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 50') 9 'i't Depth Filler Material (Below I TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITIO_N DESTRUCTION 1.)O(No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residece-J Commercial Other Number of living units: JJ IIII r �N�.Number of bedrooms�r _ Character of soil to a depth of�3 feet: --S i r Water table depth SEPTIC TANK 4B4 Type/Mfg f ¢= Capacity�� No, Compartments PKG. TREATMENT PLT- ❑ ' Method of Disposal Di' once to nearest: Well Foundation C 1 Property ine s b s LEACHING LINE ❑ II & Length of lines a t .Total length/size FILTER BED tU—Dt�ance to nearest: Well w Foundation � _. Property Line XS I' L j __ I i SEEPAGE'PITS I I Dep1 Numb th 1 _- -Size — Number SUMPS ❑ Dlance to nearest: Well Foundation` Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done 6 accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Santoaquin Local Health District. ' s a Home owner or licensed agent's signature certifies the>followingt "I certify that in theperformanceof the work for which this permit is issued, I shall not employ any person in such manner as to became subject to work man's compensation laws of California." Contractor's hiring or sub-contracting signature cert[' the following:"I certify tF'at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Californianr" II I The appiicar�t t c 1 fo all r quire nspecY risme+ mglete drawing on r verse s'd' fI llll i 1j Sign � � e_Q R� � Title: pate: FOR DEPARTMENT USE ONLY. . r Application Accepted by ,Date vv- Area l V 1 t -,ti , � Q Pit or Grout Inspection by Date ! Final Inspection by �a I Date LL Additional Comments: d E��L i�r. L, CA ` -' ❑ Stk 466-6781 ❑ Lodi 169-3621 ❑ Manteca 823-7104 ❑ Tracy 835-fi385 Applicant - Return all copies to: E'vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 17 FEE _ AMOUNT DUE 'ANOVNT REMITTED CK RECEIVED BY - INF[] CASH DATE^ PERMIT N0. +,EH 13.24 IREv-1/fa 51 D 7 EH 14-28 ,� �„� �� I