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3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 li Local Health District. Job Address City C Lot Sizei+9i PM Owner's NameAddress •> � - 1JQ� ' y Phone Contractor Ady # Address `, License Noo Phone. TYPE OF WELL/PUMP;- L NEW WELL D 'WELL ❑ DESTRUCTION Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑. `DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USt-1 '"TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing F1 Public C Other Specifications I7 Delta Depth of Grout Sea) Type of Grout _ I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by ; Repair Work Done ❑ Type of Pump H.P I - _ State Work Done-'' rs Well Destruction ❑ Well Diameter ealing Material (top 501)^ _ %1 Depth :"<:Filler Material (Below 50'-).- - — _ ; , I TYPE OF SEPTIC WORK: NEW INSTALLA_ TION•,>( REP_AfIi7ADDITION I"1 DESTRUCTION"! I (No septic system permitCed'if public sewer is �" f dnstallation will serve: Aesidence�-� �e rtf available within 200 feet.) Commercial _ �1 Other ' Number of living units: _ Numberrof bedrooms�- :Z_.-_ tr- Character of soil to a depth of 3 feet: < ' -+ *� V R,,. Water tabld depth SEPTIC TANK �'�❑ ype/Mfg + Capa, (=` I t PKG. TREATM Nf PLT. ❑ "-" p y No. Compartments Method of Disposal Distance to nearest: Well Q Foundation r Q r- . Property Line �_� LEACHING LINE No. & Length,gf lines ,L—`Total length/size---- FILTER BED A © Distance to nearest: Well��__Foundafione07T sT Property Line� / t SEEPAGE PITS I I Depth Size j Number ` SUMPS L Distance to nearest: `;� Well + Foundation ` I DISPOSAL PONDS ❑ — Property Line hereby certify that) have prepared this application and that the work will be done in accordance with San c rules and regulations of the San Joaquin Local Health Di'st'rict. Joaquin bunty ordinances, state laws, and ._ r.-._tom _ �., Home owner or licensed agent's signature certifies the foilowing: "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 subiect'to workrhan'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 tion laws of California." P Y persons subject to workman's compensa- tion applicant must call or all required inspections. Complete drawing on reverse side. { Signed X r i m.4 _ w If i Tifl _ Date:•. FOR DEPARTMENT USE ONLY Application Accepted by r I Date 7' Area f Pit or Grout Inspection by ;o Date Final Inspection by ate Additional Comments: 1' r ❑.Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Ser ces 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,,CA 95201 / Y '"�""" FEET ' AMOUNT—DU-E, AMOUNT REMITTED_ CK INFO RECEIVED] BY CASH DATE PERMO t.EH 13-24{REV.I/ri 51 '1 EH 14-28 L5'