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APPLICATJON FOR PERMIT --� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in,,Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit io 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. 18.62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r / (� } p y� e�-7 Q V t r.-� a :d F_ ,� Rdd r,., i f.A J' fin* �i�a �L / a-," Jon Aooress M '" - --- -•-- , ,a -- j� j &// / D U i^ _ Owner's Name Address . Z �' Phone 41:; ~ 3 Contractor's Na !license No.3 ' TYPE OF WELL/PUMP:. NEW WELL B-' WELL REPLACEMENT ❑ DESTRUCTION ❑ '7L4 S _ ZO - PUMP INSTALLATION E�" SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 14 Cs SEWER LINES 17:5 DISPOSAL FLD. 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 ii` fZ-Dwr estic/Private i 0-ergvel Pack ❑ Tracy Type of Casing Te Specifications ❑ Public } ❑ Other ❑ Delta Depth of -Grout Seal r�i Type of Grour ❑ Irrigation 491 -4 -Approx. Depth ❑ Eastern �- ` H, P. Surface Seal Installed by "Z- State Work Done Repair Work Done Elj Type of Pump Well Destruction Cl Well Diameter " Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 2 REPAIRGADDITION ❑ 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ -` Method 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 l � k SEEPAGE PITS❑ Depth Number _Size SUMPS i❑ Distance to nearest: _Well Foundation Property Line - IDID SPOSAL PONDS `j ❑ i II 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. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. omplate drawing on reverse "side. I a Signed Title: Date: 8 FOR DEP RTMENT USE 0LY Application Accepted by# Date y — Area / Pit or Grout Inspection by Data 0�vFinal Inspection by Date -3- ' Additional Comments: v ❑ Stk 466-6781 ❑ Lodi 369-36221 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 MEV. 10!93) EH 14-26 FEE INFO . AMOUNT DUE AMOUNT REMITTED i K H RECEIVED BY DATE PERMIT"NO. . '