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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE„ STOCKTON, CA 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 Local Health District. /f 1 Job Address r 1 zq(0 e�� l�/ � - City �ldGlftYr, Lot Size�ZQOki S__� PM rJ7 /J� Owner's Name S Oc' dpi �C�7r/>g1Y1 ' Address ✓�C��0 ! VOW(/ Phone O r / Sf - Contractor tx7�p P p., n .Address2Z0 2or�l� .� Zs�' License No,G5� phone fb- Z-"zSZ9 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT L7 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 19 /YjD,,;tirl�j DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES Z06 DISPOSAL FLD. PROP. LINE ),S' t 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 2 i ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing P+/G Sc1� Specifications 1'1 Public �n Other �1 Delta Depth of Grout Seal Type of Grout I I Irrigation -[-t_1Approx. 'Dept F�`d DO Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump �'1- H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material flop 50'1 Depth - Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) O 1 Installation will serve: Residence Commercial_ Other I Number of living units: NumbFer of bedrooms i Character of soil to a depth of 3 feet: t Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J PKG. TREATMENT PLT. ❑ Method of Disposal Distance fo nearest: Well Foundation Property Line I LEACHING LINE Cl No. & Length of fines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line r r {..k SEEPAGE PITS i I Depth I Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 � 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." Contractor's 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." The applic nt must call for sA required inspections. Complete drawing on reverse side. i TItIe: Pt�J �/4 QL C-1111 Date: FO DEPARTMENT USE ONLY E Application Accepted by Date �`� Area , Pit or Grout Inspection by Date �Fi{naall Inspection by Date Additional Comments: �- cnn.�s\S.-e tw� „c1l�Vr o�.�..�a • _ ❑ Stk 466-6781 ❑ Lodi 36,9-362 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 E FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I INFO +.EH 13-24IREV.11A5) EH 14-28 •Q a r �p r -. e r