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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Address 3 6 � 7 City��yLot Size '" _7 PM ?1e/C✓C lGti � tJ �j /`r/4- � � —,g Owner" Nar Address Phone 3 Contractor L `-% �. ��5)dress r-f �t,fs License No Phone_/ s t2P21 II TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT DESTRUCTION ❑ 1 PUMP iNSTALLATIION ICY SYSTEM REPAIR ❑ OTHER ❑ ! f DISTANCE TO NEAREST: SEPTIC TANK _sZ SEWER LINES I'd- DISPOSAL FLD.�¢¢,,rr�� PROP. LINE N FOUNDATIO ! AGRICULTURE WELL OTHER WELL,4L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIc NS �� f ❑Zustrial Open Bottom ❑ Manteca Dia. of Well ExcaDia. of Well Casing estic/Private Cl Gravel Pack E] Tracy Type of Casing-2w ' Specifications ['l Public HCl Other n Delta Depth of Grout Seal Type of Grout 2 1 I Irrigation 2,W-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump -10&0 _ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [tap 501 Depth. Filler Material 16elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION 1.1 DESTRUCTION I 1 iNo septic system permitted if pu sewer is available within 200 fe Installation will serve: Residence _ ;Commercial_ Other Number of living'units: Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth .SEPTIC TANK apacity No. Compartments lll... PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well o Property Line LEACHING LINE D No. & Length nes Total iength/size FILTER BED ❑ Dista o nearest:. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that 1 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 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." The applicant must c II for all required ins ctions. Complete drawing on reverse side. Signed Title: _ Date: -3 2 4-77 l 4. FOR DEPARTMENT USE ONLY I1 Application Accepted by A21 Date —_Z— ��Area 'k k Pit or Grout Inspection by e Date �� Final Inspection b 711 Date-3 Additional Comments: ❑ Stk 466-6781 E Lodi 369-3621 ❑ Manteca 823-7W ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CUK RECEIVED BY DATE PERMI' EH14-2971'NO. ZU iEH 3-24 IREV.tix51 V� 1 � � '�, /'-� w -Li � L.J r`7