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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (26) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in'Triplicate) 3r. 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 792 k/_14/d/ F /r City Lot Size of rkV PM Owner's Name k///—/,/,mm Address= Phone . Contractor ;PXTJam_ F Address Zl o License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A7 SYSTEM REPAIR_0_ OTHER El T DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES i DISPOSAL FLD. PROP. LINE FOUNDATION AGRICI�LTURE-WEL'L 5• ��®`(OTHER WELL PITS/SUMPS —INTENDED-USE TYPE-OF WELL PROBLEM-AREA---GONST•RUC-T•ON-SPEGIFIGATIONS�`� F1 Industrial El Open Bottom L-1MantecaDia. of Well Excavation .Dia. of Well Casing Domestic/Private kGravel Pack ;❑ Tracy Type of Casing Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout SealrType of Grout ❑ Irrigation fol _Approx. Depth ' ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _- 'fig H.P. State Work'Done Well Destruction ❑ Well Diameter i I Sealing Material (top 501 Depth Filler Material (Below 50'1 I I S TYPE OF SEPTIC ORK: NEW INSTALLATION 11REPAIR/ADDITION ❑ DESTRUCTION 71 (No septic system permitted if public sewer is 1 ( available within 200 feet.] Installation will erve: Residence_ Commercial_ Other Number of livinj'l units- Number of bedrooms I Character of soil to a depth of 3 feet: j 'Water table depth4. SEPTIC TANK ❑ Type/Mfg I i 1 Capacity 11 No, Compartments i r PKG. TREATME J PLT. ❑ r� Method of Disposal Distance to nearest:] Well Foundation Property Line I r I LEACHING LINE ❑ No. & Length of lines_ i Total length/size FILTER BED ❑ Distance to nearest-- Well Foundation Property Line+ + SEEPAGE'+PI)TS z�� ElDepth Size Number SUMPS ❑ Distance to nearest: Well Foundation— �f�Property Line �'r DISPOSAL PONDS.r ❑ I hereby certify that`ItiL ave prepared this application an`d 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 bistrict. t L I I Home owner or iicensed7agerit's signature certifies the fallowing: "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 fsubject to workman's compensation laws of California?" Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performanceof the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i fir - y { The applicant m t c I f all re uired inspections. Complete drawing on reverseido+ ^ Signed X __ �—� Title: - Date: FOR DEPARTMENT USE.IIoNLY.—r--- i Appl on Accepted by _ f r" r ' Date —13 of w Area r Pit or Grout Inspection'by i Date a rJ Final Inspection by Dated / Additional Comments: a Cl Stk 466-6781 ❑ Lodi -3621 A# ,'_;7Q nteca 823 7104 ❑ Tracy 83�r6385, A�pli nt,- Return all copies to: Environmenf#al Health rmi-7$ervices•1601 E: Hazeltor',Ave., P.O. Box 2009, Stk.,,CA 95201 FEE r INFO AMOUNT DUE 'AMOUNT REMITTED CASH RECEIVED BY 1 1 DATE +EH 13-24(REV.3/ s) � EH 14-28 .I sus a '.SCG �/1� 't