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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i'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. �, , Job Address /7flwAX _ City Lot Size /y PM v PSG, IJLJ i (e- 00l,--$ 't G r�G._ v g. Owner's Name Address Phone —arm Contjactor S Addres DlTt / �/�- wkicense Noosoodz Phone � 7w TYPE OF,WELL/PUMP: NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION © a t r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t -_bISTANCE'TO NEAREST: SEPTIC TANK ( ``SEWER LINES DISPOSAL FLD. PROP. LINE r 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 ❑ Gra vel Pack ❑ Tracy Type of Casing Specifications ❑ Public n Other F1 Delta Depth of Grout Seal Type of Grout I i Ifrigation --Approx. Depth 4 i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done z Well Destruction ❑ - Well Diameter `l Sealing Material-Itop50') Depth Filler Material {Below 501 Y ' I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION -DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) installation will will serve: ^Residence :Commercial - Other ►LE Number of living units' Number of bedrooms_ �� $ 4 Character of soil to a depth of:3 feet: �ill7.B� '" k Water table depth SEPTIC TANK ❑ Type'/Mfg Capacity 'No. Compartments �..i PKG. TREATMENT PLT. ❑ ► Method of Disposal f Distance to nearest: Well Foundation] ' Property Line 7� LEACHING-LIN f 0 No. & Length of lines Total lengthlsize FILTER BED r L1 Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation f Property Line DISPOSAL PONDS Cl -:, I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, tnot rules and regulations of the San Joaquin Local HealthDistrict. 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 employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring of 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." _.y t The a0plicant must call for all requir d i pec' ns: Complet drawing on side. E` Signed Title: Date: F R DEPARTMENT USE ONLY Application Accepted by `' y Date 's (3 I 'Area Pit or Grout Inspection by Date Final Inspection` by Date s Additional Comments: f.:.. ❑ Stk '466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 f ❑ Tracy 835-6395 Y Applicant - Return all copies to: Environmental Health Permit/Services-:1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' 4 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT•NO, ' + EH1 3-24[REV,I/K 51 .'� �� 'I r (,r l c? �J• r l< 3� L "o EH 14-28