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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone (2691466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) fi ! �� # . 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.tie _-. 4 _ .F + Job Address' "' + V,41 , /[!J / City C G S..Lot Site G - PM Owner's Name Address �� _ - n �ione s/// l , �-- �✓ Contractor's Name [�L F License No. Q Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTAUC.TiON ❑ '' PUMP INSTALLAW, `_ SYSTEM REPAIR ❑ OTHER 0. � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL. PiTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W f E3 industrial E3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack `0 Tracy 7Type of Casing p ' ' �, Specifications ❑ Public 11 Other 11 Delta Depth of Grout Seal ❑ Irrigation "�'�` '�. T pe of Grout +rJ ©?q�Approx. Depth--- ❑ Eastern * 'Surface Seal Installed by c Repair Work Done ❑ Type of Pump H.P. State Work Done Well.Destruction ED Well Diameter Sealing Material (top 501) I, Depth Filler Material (Below 50') - V� TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION.❑•.(No septic system C) i permitted if public sewer is Installation will serve: Residence— Commercial� Other ' available Within 200 feet.) -[ t Number of living units: Number of bedrooms • �� - � , Character of soil to a depth of 3 feet: Water tabte-depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG:TREATMENT PLT. F11Method of Disposal Distance to nearest: Well Foundation Property Line--- C 4 LEACHING LINE ❑ No. & Length of lines Total length/size: FILTER BED ❑ Distance to nearest: Well $ Foundation Property Line`s SEEPAGE PITS ❑ Depth Size Number SUMPS ID DistaProperty Line . nce to nearest: Well Foundation �' � 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 p 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 Cj 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 wwork,for which this permit is issued,I shall em to tion laws of California" �. x �. i� P Y Persons subject to workman's compensa- tion canZmu � r r d inspect' ns. Co ete drang on reVerse ide. Sign . wiI,' y.� ed Title: ff�5 Date: FOR DEPARTMENT USE ONLY . -7 Z, Z Application Accepted by Date V �` Pit or Grout Inspection by Date pe y �,�, - " Final Inspection b � ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8237104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED. CK INFO CASH_ RECEIVED BY z" DATE PERMIT"NO, + EH 1324 IREV.16/834 43-00 i EH 14-26