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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. qC r Job Address ! /of/t/•tl I 'C - - City Lot Size 6 PM k Owner's Name% Address Phone " Contract Address I. License No 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications (`l Public F1 Other 17 Delta Depth of Grout Seal Type of Grout _. (� I i Irrigation ,-A'pprox. Depth I 1 Eastern Surface Seal Installed by ,11 . t j --- Repair Work Done E] Type=of Pump-- H.P. State Work Done _ n k Well Destruction ❑ Well Diameter +Sealing Material {top 501 Depths Filler Material (Below 50'i 1 4 TYPE-0F SEPTIC WORK: NEW INSTALLATION . REPAIR 7017ION 1 I DESTRUCTION.t•I (No,septic system permitted if public sewer is available-within 200-feet.) ^te r Insta3lation wiper e.CRTs d`ence Commercial Other Number of living units J Number of ooms /�y Character of soil to a depth of 3 feet: 1 :� •' • Water table depth A00 ., .fT'f V SEPTIC TANK :Type/Mfg '*•�`"-Capacity_- No. Compartments PKG. TREATMENT PLT. ❑ _ f `a Method of Disposal ;'Distance to nearest: Well Foundation Property Line`Z.577!_ LEACHING LINE 'Ui!�lo. & Length of lines 1� Total length/size c' X n f FILTER HED 5,61 ❑ stance to nearest: Well_�� Foundation _ Property Line I SEEPAGE PITS' to Depth Size * Number ` SUMPS ..: Cl Distance to nearest: Well lJi-Foundation IQ___ Property,Line `s n k DISPOSAL PONDS © I I hereby certify that I have prepared this application and'fhai t6 work will-be`done in accordance with San-oaquin daunty 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 C 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 applicant mu all for ail uir inspectibns. Complete drawing on reverses Q r Signed X f Title: 0 � • Date: Q �� r FOR D ARTMENT USE ONLY f"� Ap )(cation Accepted by Date Area d it r Grout Inspection by' Date . _ Final inspection by' Date72 dditional Comments: C1 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 CASH o174 �7 + EH 13-24 IREV.i/x 51 �. 01 EH 14-2t3 i