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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA k' Telephone (209)'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 k Local Health District. Jab Address Z 2 City .S _.� Lot Size PM Owner's Named A 0 d46-1 C-Zr . Address 1722 f Phone M ' Contractor's Name .�/�rE'!.S fa` �$"d t>T! License No. 1,54! ,�{/3 _ Phone _Zi6 6 —9,6 Q TYPE OF WELL/PUMP:u--�-.�...-NEW-WEL•L 0--v-�WEL-L REPLACEMENT ❑ DESTRUCTION ❑ �J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �1 i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALFLD:" " _ PROP. LINE FOUNDATION AGRICULTURE WELL; OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-AREA, CONSTRUCTION SPECIFICATIONS ' 1 ❑ Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 'tel-Gravel Pack ❑ Tracy Type of CasingL Specifications ❑ Public ' L.-Other 7I_Delta ,_Depth_of-Grout*Sea] Type of Grout r ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by S Repair Work Done CJ t-Type,of`Pump H-P. 4 Sfate WUFW Done I Well Destruction ❑ Well Diameter „Sealing Material (top 501 1 r Depth Filler Material (Belo 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.. - DESTRUCTION ❑ (No septic system permitted-if public sewer is s available within 200 feet.)-;� Installation will serve: ?Residence Zcommercial_ Other Number of living units: Number of bedrooms Ar Character of soil to a depth of 3 feet: _: L/� Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT:❑ 4L Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE E No. & Length.of lines D Tota! lengthlsie- FILTER BED ❑ Distance to nearest: Well ,S-D Foundation ?cr Property Line ?2CjTdPAL'��,,, f SEEPAGE PITS #fir Depth 2,3' _ Size 3 Number i' SUMPS ;11 Distance to nearest: Well � Foundation-2-e Property Linejt_CIr 6&: DISPOSAL PONDS 40 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 employ any-person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting 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." 4 The applicant m st call for all required in pections. Complete drawing on reverse sid j Signed -- t _ Title: Date: FOR D ARTMENT USE ONLY Application Accepted by Date Area r r Pit or Grout Inspection by C Or,. Date �- '�`r Final Inspection by Date �Y 67 r Additional Comments: \ r ❑ Stk 466-6781 []-Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE INFO 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1324(REV.10183) .� 0— EH EH 14-28 I: