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-7 3?8U 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 a (Complete;in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!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 Address •f � ' C7 1r CyL. f�.Q s ` �itY of Size PM Owner's Name Address 7/ /loss �7 Contractor's Name J– f tom.. License No. 6 2 / 3 Phone TYPE, WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I1K' 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ stern Surface Seal Installed by �� Repair Work Done ef"Type of Pump u H.P. 1 State Work Done / Well Destruction 11S Well Diameter Sealing Material (top 50') "'� J Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) .� Installation will serve: Residence— Commercial_ Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT. F77Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well'—:__- Foundation r, Property Line DISPOSAL PONDS ❑ , 1 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 licen gent's si ature certffies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any persq in such manner aI to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i certifies the lo wing:"I certify that' the performance a ork f c is permit is issued,I shall employ persons subject to workman's compensa- tion laws of alifornia." The appli nt must c r red ins t s mg a ra side. p Signed ------ Date: � � � �� Q FOR DEPARTMENT USE ONLY R Application Accepted byiU1rA]< .> Dat y _ Area OL Pit or Grout Inspection Date Final Ins ;©/� �i'�k Inspection by �L �. Date Additional Comments: - ��Sf�gClik3 J✓ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 821-7104 Cl Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CC4�SH RECEIVED BY DATE PERMIT"N0. INFO +EH 1324{REV.101831 L f EH(426 T+ S "C t ��`