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rz APPLICATION FOR PERMIT _r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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. r r, s Job Address City Lot Size PM I Owner's Name k Address —.1 q/ `y l r I/Cl- IP�a- 'Gr Phone / Q c 1 Contractor li Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE ON 57- PUMP PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS ' ❑ Industrial LlOpen Bottom nteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private 11Gravel Pack L1Tracy Type of Casing Specifications 1'1 Public ❑.Oth 1 11 Delta Depth of Grout Sear Type of Grout _ [ f I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by `'�► Repair Work Do Type of Pump- H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORj7 NEW INSTALLATION I 1 REPAIRlADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) >\ 1 Installation will serve: Residence_ Commercial,— Other \J Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg I Capacity No. Compartments i PKG. TREATMENT PLT. L1 _.-Method of.Disposal tDistance to nearest: Well Foundation Property Line ? ' LEACHING LINE a ❑ No& Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to neare6: Well Foundation Property Line 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 District. I If 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 follow' : "I certify that in the performance of the work for which thisermit is issued, I shall employ tion laws of Cal.ornia " P P V persons subject to workman's compensa- tion The applican usic I for all ire 4 spe ions. Complete drawing on reverse side. Signed X Title: G If Doe ate: FOR DEPARTMENT USE ONLY. Application Accepted In Date---�.-v l-- _ Area Pit or Grout Inspection by Date Final Inspection by F Date 2 p� Additional Comments- sZ WP",- 4- O Stk 466-6781 ❑ Lodi 3 -36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Q-1 s 6 L 4-bd L a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,:P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE j AMOUNT REMITTED CK INFO RECEIVED 'Yr. DATE. PERM17'NO. ' + EH 13-24 1REV.1/8 5 1 EH 7 4-28 ��