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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. 18652 for well/pump and the Rules and Regulations of the San Joaquin Local Health District 1� taut Vz Job Address / � fi=`^ ,y 'T'�` City df'VLot"Sita; PM Owner's Name �B Address S� AD Phone f Contractors Name ' _.License No. � Phone, O G TYPE OF WELL/PUMP: NEW W L ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 r` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES _ ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL---PROBLEM AREAACONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottam ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications W ❑ Public ❑ .Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation - r Approx. Depth ❑ Eastern—Surface-Seal Installed by r" Repair Work Done ❑ Type of Pump _ H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below (" r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/A DITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.i Installation will serve:-Residence Commercial Others Number of living unit E umber of,bedrooms "Character of soil to a depth.of 3 fee �fl g/" } Water table depth C9 ASEPTIC TANK ❑"Type/Mfg] g Capacity' No..Compartments a PKG. TREATMENT PLT. ❑ r + �' Method of Disposal Distance to nearest: Well Foundation Property Line ,e LEACHING LINE & Length of lines Total length/size O f FILTER BED ❑ r Distance to nearest: Well * Foundation r Property Line SEEPAGE PITS ��;Oepth Size Number A i SUMPS "❑� Distance to nearest: Well /:!�_a Foundation !n "70' Property Line DISPOSAL PONDS ❑ i E 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.,- ,4 f 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 person in such manner as to become subject to workman's compensation'-laws of California." Contractor's hiring or sub-contracting signature P Y anY certifies the followin : "I certify that in the performance of the work for which this permit is issued, I shall employ persons subjectensa- to workman's com p tion laws of Cal' rn f Y J I The applican us cal all r it d ins coon Complete drawing on reverse side . t fi Signed Title: Date: 0 3— ' OR DEPARTMENT USE ONLY a i x A licaiion Accepted bye Date Pit' r Grout Inspection by � ate ��^Final Inspection by_��-��- - Date�g�� Additional Comments: ? { ❑ Stk�-466-6761 Ll Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 l ' Applicant= Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,"Stk., CA 95201 FEE 22 INFO IAMOUNT DUE ' AMOUNT REMITTED CA$H RECEIVED BY\ r DATE PERMIT"NO. EH 13-24 MEW.101631 R tib, 975 A V37 I EH 14-26 i ♦