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APPLICATION FOR PERMIT 'E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA L �Z �i Telephone (209) 466-6781 ` li PERMIT EXPIRES 1 YEAR 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 L �/ s fl 7 -57-. s T1{ 4 City Lot Size PM /(owner's Name 1 A� t� Address `��`� s r �9-1 S TIC AO Phone 2-7 Y 6 3 it ,Contractor Address License No. Phone TYPE OF WELL/PUMP: '1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS R INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom If Manteca Dia. of Well Excavation ❑ Domestic/Private F1 Gravel Pack Dia. of Well Casing ❑ Trac Specifications I ! Public y Type of Casing I� Other Cl Delta Depth of-Grout Seal Type of Grout I I Irrigation _A pprox. Depth Repair Work Done El Type sof Pump I 1 Eastern Surface Seal Installed by H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top So'),- Depth 0')wDepth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l 1 DESTRUCTION {No septic system permitted if public~sewer is I 'I Installation will serve: Residence_ Commercial— Other available within 200 feet.) f Number of living units: Number of bedrooms f J Character of soil to a depth of 13 feet: SEPTIC TANK "Water-table depth ❑ Type/Mfg ! Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 f Method of Disposal I Distance to nearest:"Y Well-- -FoundationI' Property Line LEACHING LINE ❑ No: & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ,I Property Line r SEEPAGE PITSi I Depth Size SUMPS — Number L-! Distance to nearest: Well Foundation DISPOSAL PONDS ❑ .r Property Line 1 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 Di§trict. 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." If I The applicant must,caLll_for all required inspections. inspections. Complete drawing on reverse side. Signed X iCI �O-L4?- X(o Title: /�� t I "- Date: ` `c1/_1 FOR DEPARTMENT USE ONLY Application Accepted by DateArea Final Pit or Grout Inspection by Date Q nal Inspection by�%� Date ✓ Additional Comments: [J ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 5-63135 Applicant - Return all copies to: Environmental Health Permit/Services 1601 EO Hazelton Tracy Aj e., P.O. Box 2009, Stk., CA 95201 li I FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY PATE PERMIT NO. i rEH1 -24fREV.1iHsi EH 14-2e