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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 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. ��. City M -C- Lot Size � A G PM Job Address AMOUNT DUE— Owner's Name..s^he1,44 a A JZ n Address Phone Name Contractor's Nam! License No. o� JUrF�� Phone o23 �� 7J TYPE OF WELL/PUMP: - ' NEW -WELL, ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARESf-7SEPTIC TANKT SEWER LINES DISPOSAL FLD._ PROP. LINE • FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'TYPE INTENDED USE OF WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of Well Casing ❑ Domestic/ Private ❑ Gravel Pack -❑ Tracy, Type of Casing Specifications ❑ Public I ❑Other — `=- - -- ❑-Delfa�-�-`-^"Depth of'Grout Seal Type of Grout n Irrigation -d--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: 'NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 7, Installation will serve: 'Re -idents Commercial _ Other Number of living units: Number of bedrooms , r1 Character of soil to a depth;of 3 feet: A Dd L # Water table depth SEPTIC TANK '❑ ,Type/.Mfg `" ^""'"' Capacity No. Compartments kv PKG, PLT.}Q• - Method of Disposal TREATMENT �„ Distance to nearest: Well Foundation Property Line ,❑ LEACHING LINE No. & Length of lines Total length/size d FILTER BED ] Distance to nearest: Well Foundation � Property'Llne �� T SEEPAGE PITS , '❑ Depth Size -Number SUMPS- ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ -. 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, I shall employ persons subject to workman's compensa- •tion laws of Calif6rnia." f The applicant must call for all r uired inspections. Complete drawing on reverse side. Signed /li s Title: n� Date: �6 — — Z Application Accepted by Pit or Grout Inspection by I L FOR DEPARTMENT USE ONLY Date 2 Area ^� Date Final Inspection by 4V Date �r Additional Comments: ElStk 466-6781 ❑ Lodi 369-3621 ❑ 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 (REV. 10183 EH 1428 FEE INFO AMOUNT DUE— .- AMOUNT. -REMITTED_ '_ ;CK # ASH—" CASH— r RECEIVED BY "�`" - � DATES '� -PERMIT 'NO.�- • S` �� to tv-1-3