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;7Sa APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 52091 466-6781 PERMIT EXPIRES 1-YEA'R'FROM DATE ISSUED (Co.rnplete 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.54.9 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ' i w' 1 ` Ci �`—'� Lot Size PM Job Address City A Owner's Name � / Addressh 7` q, c a`�� - Phon J �� Contractor Address 4/ } License Noj(. 2 3 Phone (o TYPE OF WELL/PUMP: NEW WELL ❑ --`WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR IF' OTHER ❑ 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 I Dia. of Well Excavation Dia.-of Well Casing El Domestic/Private LlGravel Pack ❑ Tracy ' Type of Casing Specifications ❑ Public ❑ Other ❑ Delta k Depth of-Grout Seal Type of Grout ❑ Irrigation – � t.,---Approx. Dept ❑ Eastern { Syrface Seal Installed by Repair Work Done LP' Type of Plump H.P.` � t State Work Done Well Destruction— -AE] s Well Dii`a--meter } "` '�`' 4-2�-,----Sea1ing Material (top 50.) � { E Depth s FiAerMaterial (Below 501) A l 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 + r & Q Number of living units: Number of bedrooms Z Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation I Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation` Property Line .� SEEPAGE PITS ❑ Depth Size s Number I SUMPS ❑ Distance to nearest: Well Fxqundation Property Line t DISPOSAL PONDS ❑ -- I. 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. V; l 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 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." arn yf'" rt The applicant st c If for all u' d inspections. Complete dra ng o reverrsse`side. S ' Signed e: .."Y`� _Z ." '' i [ •a FOR D PARTMENT USE ONLY }w- ��i Application Accepted by i Dat Ar f Pit or Grout inspection by Date Final In's pection by A_ D Additional Comments: "`A ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 L ❑ Tracy 835-6385 ,�^�,,,,�'.�. Applicant- Return all copies to: Environmental Health Perox mit/Services 1801 E. Hazelton Ave., P.O. B2009, Stk.i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO CASH + EH 13.241REV.t/55} _�� s v\ EH 1¢28 F _ -t