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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED_ 4 (Complete in Triplicate) y 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 y Local Health District. Job Address zl ® F14F City Lot Size PM Owner's Name 1 ` w 't4vddress _7 04' IV— Phone Contractor Address license No. Phone_ I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION P--- PUMP -rPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ n I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f l Public Cl Other 1 ❑ Delta Depth of Grout Seal Type of Grout I Irrigation - _.Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done_ r Well Destruction 2-- Well Diameter r( Sealing Material ftop Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is S available within 200 feetA Installation will serve: Residence_ Commercial— Other } Number of living units: Number of bedrooms fCharacter of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance earest: Well Foundation Property.1-ine I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest ,Well Foundation . Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared tliis 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 Diltrict. 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 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica ust call for all-req fired inspections. Complete drawing on reverse side. Signed X j Title: 6 ��„ _ Date: ZZ 1 !,0.5 DEPART NT USE ONLY Application Accepted by Date a Pit or Grout Inspection by � Date Final Inspection b� Date /r Additional Comments: F ❑ Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNTfREMITTED CASH CK 11 RECEIVED BY DATE -Q PERMIT NO. + +.�H is-2s (REV.o H 5J C7t7 � . (I(� / 4 q �00 �O 0;0 21 EH 1426