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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. -^� 1 Job Address / >7 City-554l0 Lot Size PM f , o(i SI'T (1 Owner's Name rt CC Address i _ (21, (5- 7 Phone 9J — 4/7�U fContractor Address ®q eTo ^ License_No. _ Phone 6_0 TYPE OF WELL/PUMP: NEW WELL ❑~ WELL REPLACEMENT ❑ DESTRUCTION ❑ F' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑y a OTHER-0 DISTANCE TO NEA REST:_SEPTIC TANK SEWER_LINES A> "' ' DISPOSAL FLD. PROP. LINE -,�--- _ _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation._ �. _ __ -Dia.-of-Well Casing r Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public ❑ Other Cl Delta Depth of°Grout Seal Type of Grout _ ] Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. �_ } State Work Done Well Destruction ❑ Well Diameter Sealing_Mat re al Itop 50') ' Depth Filler Material IBelow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION [ 1 REPAIRIADDITION *0"DESTRUCTION i I (No septic system permitted if public sewer is f ' available within 200 feet.) 6 Installation will serve: Residence� Commercial--2- Other a Number of living units: _J__ Number of bedrooms ' " Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK LI Type/Mfg r f Capacity. No. Compartments PKG. TREATMENT PLT. ❑ `\ } Method of Disposal ' Distance to nearest: Well' Foundation— Property Line I - i LEACHING LINE L� No. & Length of lines Total length/size l FILTER BED ❑ Distance to nearest: Well O ` Foundation !q 40_ Property Line _(_ SEEPAGE PITS I Y Depth Size i� — Number SUMPS L1Distance to nearest: Well D D Foundation lad Q 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 JoaquiniLocal 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st calf for re ireZicti 1os. Complete drawing on reverse •de- .I Signed X Title: Date: r FQH DEPARTMENT USE ONLY f Application Accepted by + Date 3 �Z Area Pit or Grout Inspection by { Date Final Inspection by ,,—, Date Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVE[) BY DATE PERMIT•NO. +.EH13-24{REV.iig5Y -R 119 t6t) C to 17 V9l flAe�=�"1Y�'2- [ L EH 14-28