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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 I-PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED z (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. 16&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City " A) Lot Size PM Owner's Name Address (J- ( r 1 r Phone 1 e /fir- 'l .� ) � _ a 0 T I ��11 t Address. + License No.� Phone�� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK..{ SEWER LINES _L_ , nn DISPOSAL FLD.� PROP. LINE ` FOUNDATION IO AGRICULTURE WELL 1 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_P_ack ❑ Tracy Type of Casing �S7P�1� Specifications _ i"1 Public n Other 1 ❑ Delta Depth of Grout Seal e_- Type of Grout I Irrigation =.:Approx: De th ' L.l Eastern 1 Surface Seal Installed by Repair Work Done Type of Pump . IYI H.P.' State Work Done Weil Destruction ❑ Well Diameter. Seal g Material Itop 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I.I,w DESTRUCTION I 1 INo septic system permitted if public sewer is - -- available within 200 feet.) Installation will serve:^Residence° - Commercial _ 'Other""''"""'"""'""-` 1G'* i Number of living units: Number of bedrooms , '� s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 1 Capacity f No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation.- ? Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance fo_nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth 1 Size _ Number SUMPS Irl II-Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 ` �t_ 11 -I 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-JoaquinLL•ocal Health Di1trict. 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." ;1. The applica st call for all required inspectio s Complete dra ing on r arse side. /►/� f r ' yam Signed o !/ 1 ��, Date: ` P � � itis: &FR.DEPARTMENT USE ONLY Application Accepted by V Date Area Pit or Grout Inspection by Date Final Inspection by Date_ Additional Comments: ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE PUNT DUE f AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. I INF *.EH 3.24RV.1i85) D JOS-. 00 3-7 `P 4:55 I 1 t,Q J�Q '00-114 -2r J� Li EH 14 9