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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. Job AddressP2 1JZ E City ' Lot Size,'N2 X6 LC PM Owner's Name / t, A4ddress Phone ` 4 l' V Contractor� * ddress. /d/....L= �? e' License No. J� Phone 22 TYPE OF WELL;PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ OWELL EM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWE LINDISPOSAL FLD. PROP. LINE FOkDATION AGRIC LT OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public f7 Other n Delt Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth l 1 stern Surface Seal Installed by _ Y Repair Work Done D Type of Pump H.P.. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 _ Depth Filler Material IBelow 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ( r REPAIR/ADDITION I I DESTRUCTION 1-1 (No septic system permitted if public sewer is r .� available within 200 feet-1 l Installation will serve: Residence Commercial Other _ l Number of living units: Number of bedrooms w ^ Character of soil to a depth of 3 feet: A Water table depth (t} SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� Method - o I �Distance to nearest: Well 0 Foundation Property Lin O LEACHING LINE ❑ No. & Length of lines To al lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation,__� Property Line r 1 SEEPAGE PITS i I depth Number SUMPS Ll Distance to nearest: Well undation A 1d) Property Line 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 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 mariner 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." Tfie applicant srcall for-Af-equired i spections. Complete drawing on reverse side. Signed X Title: Q� ✓1.f�t Date: to a.�-�� OR DEPARTMENT USE ONLY p� Application Accepted by TJt,/A 1 c "Date C7 V Area Pit or Grout Inspection by Date Final Inspection b / VI Date r 0 Additional Comments: �� _,......,.,_. ❑ Stk 466-6781 El 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 INFO �OJUNT DUE AMOUNT REMITTED CASH K 4J RECEIVED BY BATE PERMIT-NO. r.EH 13-14 1REV.I i N 51 /Q�o '�i^7/ { � EH t4-26 11 / '-' r