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I `l " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 h PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED ' (Complete in Triplicate) I 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. .P`Q LCJ` Job Address City 'Lot Size PM I �.� t A0l VZ JZ Owner's Name Address ^-7 �•-- !"--=� Phone ~ Contractor /Y S Address I&AoLdtfOZ License No.fl�o l Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONW PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications r hl Public L] Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth 1.1 Eastern Surface Seal Installed by Repair Work Done ❑ f Type of Pump T/ H.P. State Work DoneISr"X/ Well Destruction Well Diameter Sealing Material (top 501 Depth l } Filler Material (Below 501 Af y j TYPE OF SEPTIC WORK:,. NEW INSTALLATION (I REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is k s available within 200 feet r Installation will serve: Residence= Commercial Other i Number of living units: t Number of bedrooms t k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑, Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I '' 4 Method of Disposal Distance to nearest: Wel! ' Foundation Property.Line I 1 �. LEACHING LINE ❑ No. & Length of lines ` Total length/size t FILTER BED ❑" Distance to nearest: Well r-, Foundation" Property Line A SEEPAGE PITS .l I+I Depth Size " Number SUMPS t LZ Distance to nearest: Wel! Foundation Property Line DISPOSAL PONDS ❑ 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. 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- j 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." x t The applicant f all actions. Complete drawing-on rev f Signed X — Title: Date: m.. F FOR DEPARTMENT USE ONLY I[ Application Accepted by 77 Dat Area ! ',A- A d . Y-.. � � Pit or Grout Inspection by Date Final Inspection by Date j],.....,.A��/r��/y - f' Additional Comments: ............. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 823-7104 ❑ Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { r ` FEE AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIVNO. / I INFO +.E 13-24 IpEV.r/K 5f !a7 -lei EH 14-28 ! tic T k