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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ON AVE., STOCKTON, CA m T C)h { Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. it Job Address 4 0 d ro-olar'-AL, City Lot Size_Mro X300 PM 4 Owner's Name z 9, C 14A9 - �Address cc, Phone � + Contractor Address 71) lF— Ankicense'-N o". �I s7 2-Phorie 1 7 0 TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT'❑ DESTRUCTION ❑ •-- PUMP INSTALLATION ❑ SYSTEM REPAIR �OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '� DISPOSAL FLD. PROP. LINE ! FOUNDATION —�� AGRICULTURE VELL f OTHER WELL �� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !+ I F-1Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ax Specifications IOq q FI Public El Other n Delta Depth of Grout Seal _t °.; ,� if,.,Trrype of Grout—Coc. � I I Irrigation -ApproxDepth { I Eastern Surface Seal Installed by tiL - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth d Filler Material (Below 501 " TYPE OF SEPTIC WORK: NEW INSTALLATION l-1 REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ''"Installation-will=serve:--Residence—""Commercial"- =Other— --- ". t Number of living units-- —' Number-of-bedrooms- . Character of soil to a depth of 3 feet: _ --- Water table depth - SEPTIC TANK ❑ Type/Mfg Capacity- No. Compartments PKG. TREATMENT PLT. ❑ ............ r Method of Disposal t Distance to nearest: Well Foundation Property-Line LEACHING LINE ❑ No. & Length of lines Total length/size t t FILTER BED ❑ Distance to nearest: - Well ?Foundation Property Line' � Q SEEPAGE PITS 11 Depth Size lNumber �' a SUMPS ❑ Distance to nearest: Well Foundatio'rl Ij . . Property Lines 't t DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin.counly ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. _ Home owner or licensed agent's signatuie 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." Coritractw s hirin"gror sub-contracting signature 'certifies the following: "I certify that in the performance of the, otk for which this permit is issued,I shall employ persons subject to workman's compensa- lion laws of California." r The applicant st ll for all required inspectio omplate drawing on reverse side. Signed Title: ° Date: FOR DEPARTMENT USE ONLY I Al?plication Accepted_b _ Date. v Area 0. Pit or Grout Inspe ro Date Final Inspection by Date Fj I Additional Comments: l ❑ 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 96201 m FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO I a EH 13-241REV. iinsi �� Q i EH 14-26 � , s