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�/,7 7Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. €� Job Address 7 ,'"" City Lot Size PM t k t - k �- /63 { r)Q tv !�'• ,t"5 � Address 1 � Phone Owner's Name C Contractor �J�•c-C.o� fi' Addres � "<� License N/6 1-3?3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I . INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial s� Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1;'Domestic rrlPate C7 Gravel Pack ❑ Tracy Type of Casing Specifications f FI Public [_1 Other 11 Delta Depth of Grout Seal Type of Grout-- ` I i Irrigation _Approx. Dep h ( I Eastern l Surface Seal Installed byg - Repair Work Done . S. kT .Type of Pump 4 H.P. State Work Done —_�—. Well Destruction —,0, Well-Dian to 6r Sealing Material(top 5Q'1 Depth I Filler;Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l 1 DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) i Installation will serve: ResidenceCommercial. Other ,a (�} Number of living units: Number of bedrooms 7r-z Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK C7 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well s .k Foundation a Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r r FILTER BED ❑ Distance to nearest: Well 'Foundation Property Line I I SEEPAGE PITS VI Depth � Size. � Number SUMPS ❑ Distance+ to nearest: Well 1 Foundation Property Line r 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 DFstrict. 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 following: "I cartify 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 ."� .._...V- _ . . - - The applicant�ist�call for all required inspections. Complete drawing on reverse side. ^7 Signed X. -t �"L'V �^ -Title: /��--" Date: •"'� FOR DEPARTMENT USE ONLY Application Accepted by Date /D �v Area Pit or Grout Inspection by Date _ Final Inspection by �� Date Additional Comments: r ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I 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 +.EH13-24(REV.t/H sl —Z:;1oy' EH 44-2e