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k f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA _ R Telephone (209) 466-6781 PERMIT EXPIRES .1 YEAR FROM DATE ISSUED i .a(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 Courity Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 3 Job Address City of Size PM Al ZY Owner's !Name Y �» re ` C�� Address _�, 5/�C�, Phone - Contractor— Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ -SYSTEM REPAIR-E]_ OTHER ❑ a DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 ❑ Gravel Pack ❑ TracyY Type of Casing Specifications ! FI Public ❑ Other 1=1 Delta Depth of Grout Seal Type of Grout _ { I I Irrigation'4 _.Approx. Depth, I I Eastern Surface Seal Installed by t Repair Work Don_e ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 5014 t4 Depth Filler Material ;Below 50'? '-3YPE OF SEPTIC WORK:-NEW INSTALLATION 11 REPAIRIADDtTION I11 DESTRUCTI ] INo septic system permitted if public sewer is available within 200 feet.) �. Installation will serve: Residence_ Commercial__ Other , r» Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC.TANK ❑ Type/Mfg.! Capacity Nq,Compartments PK G. TREATMENT,PLT. ❑ f Method of Disposal , Distance to nearest: Weli ' Foundation Property Lin61"' LEACHING LINE ❑ No. & Length of lines Total length/size t ` FILTER'BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number t SUMPS LlDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ d r 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,�aa 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 sub-contracting signature I certifies the following: "I certify that in the performance of the work for which this.permit is-issued;+shall,employ persons subject to workman's compensa- tion laws of California." - - f The applicant must call for all required inspections. Complete drawing on reverse sia"e. Si.gned X�f_.r`k ,��%f , f Title: &t-Q - /,L 'Date: 2 f t% FOR DEPARTMENT USE ONLY Application Accepted by _ a Date Zile 0 Area � ' { Pit or Grout Inspection by // Date Final Inspection by Date Additional Comments: l w ❑ Stk 466-6781 OLodi "369-3621 ❑ Manteca 823-7161 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Silk., CA 95201CK FEE 4 INFO AMOUNT DUE ci AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, 00 0 Z Om +.EH 13.14 MEV.1/H 5) _0,3S 43S2-s- -211 `-+ +" EH 14-26