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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1662 for well/pump and the Rules and Regulations of,the San Joaquin Local Health District. J �� Cit Lot Size l D A� PM Job Address Y Owner's Name �� f r 3 Address J CCk' hone 557-574-3 ConfractarFtlC?[QsuJe=H t.-; 1 ' AddressJ?f toYJ31 d License No-Jilirl2k Phone P TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1/x,0, SEWER LINES 100' DISPOSAL FLD. 6'0 PROP. LINE FOUNDATION_ AGRICULTURE WELL OTHER WELL ®1Q t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS bP ❑ Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SFS t- Specifications 12- Public ZPublic l7 Other ❑ Delta Depth of Grout Seal 100 ' vK Type of Grout. _aR' _ dSIIN-r.� a•v I I Irrigation .-Approx. Depth I I Eastern Surface Seal Installed by fi,i �_.-.-_� .t.� Repair Work Done 0 Type of Pump swb H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Y a Depth filler Material (Below 50'1 T TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) o1 Installation will serve: Residence_ Commercial Other 'V t` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth- SEPTIC epth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments --PKG. TREATMENT PLT. ❑ Method of Disposal " Distance to nearest: Well Foundation Property,Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I DepthSize Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 1 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applica ust J°or all requi d inspections. Complete drawing on revs side. v. Signed X (/rl� - Title: AIM--le F,91Z"' Date: Uft—D-E-P-AARTMENT USE ONLY p q Application Accepted by Date Area Pit or G�nut Inspection by Data %,F'mal Inspection by'T�Q �// Q Date I d-,fir' 2 � 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO !1 CASH / EH 14-28tREV.tins] �r�� l 0-0 �� q'a�, Q0 X!