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APPLICATION FOR PERMIT tir f ` SAN JOAQUIN LOCAL HEALTH DISTRICT ` tt 1601 E. HAZELTON AVE., STOCKTON, CA "1 Telephohe 1209) 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. i _ Job Address Z A - &— City Lot Size PM ` ZCa Owner's Nam r Address 9S ys Phone �/ C 7..........c".`1 -.o, 11LAJ ^ l -Z ZZ& �a'til Contract Address a�J License No. �Phone TYPE OF WELL/PUMP: Ej NEW WELL ❑ WELL REPLACEMENT.0 DESTRUCTION.,D »•- -^ �:, - �- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D r DISTANCE TO NEAREST:"SEPTIC TANK.. SEWER LINES DISPOSAL FLD. PROF. LINE f _ ' FOUNDATION AGRICULTURE WELL _� OTHER WELL PITS/SUMPS s INTENDED-.USE —TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial F .• ❑ Open Bottom; ❑ Manteca Dia. of Well Excavation Dia. of Well Casind ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications f l Public f_l Other H Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump A` cH;P. ''°! ! r. ^ State Work.Done_ Well Destruction-, ❑ '-We11,Diameter Sealing Material-Itop 501 -Depth r Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'.7 REPAIR ADDITION DESTRUCTION I I (No septic system permitted if public sewer is w 1 available within 200 feet.) Installation will serve:, Residence— Commercial Other C7 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-ft . Method of Disposal p Distance to nearest: Well Foundation _ Prooerty.Line LEACHING LINE Ll "No:•&.Length of lines _ Total length/size FILTER BED [7 Distance to nearest: Well Foundation—. Property Line I I 1r SEEPAGE PITS:--, /V- .Depth ^ Size _— Number ` 'SUMPS ❑ Distance to nearest: Well I r15 Foundation—]Q� Property Line r ' DISPOSAL PONDS ❑ _ - 1-he►eby certify that I have prepared this application and thatahe work will be done in accordance with San.Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health Ditrict:- "Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this parmit is issued, i shall not ,>employ any person in such manner as to become subject to workman's compensation IaNrs of California."Contractors hiring or subcontracting signature certifies the following: "I certify that in the performance of thetwork for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." f The applicant m 11 for all ed pections. Complete drawing on reverse Signed Title: _ Date: .� � j FOR DEPARTMENT USE 0111LY I Application Accepted byp Date I 4 r r ��j or Grout Inspection Date/ ?62f 7� Final lnsrpe(-U n by Date[ Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 513C-154385,� Return all copies to: Environmental Health Permit/Services.1601-E.-Hazeliton Ave., P.O. Box 2009,"Stk., CA 5,5201 Applicant r FEE AMOUNT DUE AMOUNT REMITTED CK RECECIVED BY DATE PERMIT'NO. [ INFO a CASH 1324(REV.t/H81 EH W2a