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fw ZA ub APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT j14k / 3 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � T ,q �LD (Complete in Triplicate) Z,A_.:..._ 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. Job Address AAi� �f6 &1b0--J EJ{ , -1 Id/S Sall City Put t4j&Cel, Lot Size PM Owner's Name Address I ` Phone 3<-2r) Contractor �D Address 3<-2r) 1"�c.l��-.e_LI VVVA License No, [}!�1/3 Phot(-209 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT '❑ DESTRUCTION kp ��p�t` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l`1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation __-Approx.-Depth l l Eastern Surface Seal Installed by . i Repair Work Done L1 Type of Pump H.P. State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material iBelow 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION l'IXAIR/ADIDIITION I I DESTRUCTION I No septic system permitted if public sewer is: ! available within 200 feet.) Installation will serve: Residence— Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F undati Property Line t LEACHING LINE ❑ No. & Length of lines Z Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line + i SEEPAGE PITS i I Depth Si Number SUMPS Ll Distance to nearest: ell Foundation Prope Line i I DISPOSAL PONDS ❑ 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 Di§trict. s 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." 3 The applicant st c for a4 required inspections. Complete drawing on reverse side. r lI�1t_3�, Signed X rz-u Cis/' Title: , r Date:' "r L l FO EPARTMENT USE ONLY Application Accepted by3^^^ Data — Ar I , a Pit or Grout Inspection DateAL 4- Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEEO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY ATE PERMIT*NO. � ! ..EH 1 -24[REV.t/H51 177- EH t4-28