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rte,,. _ .. � =•,, APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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. �j Job Addressb City-- r �1 -4 Size PM Owner's Name r` Address , - Phone 3 1 .5,? ontractor's Name . Wcense No. �� Phone _ 0 ,TYPE OF WELL/PUMP: f NEW WELL ❑ WELC-REPLACEMENT ❑ DESTRUCTION ❑ L PUMP INSTALLATION SYSTEM SYSTEM REPAIR O�' .�. � .. OTHER ❑ ',DISTANCE TO NEAREST:,'SEPTIC TANK SEWER LINES DISPOSAL FLD, ROP_. INE O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ' JTYPE OF WELL '�PROBLEMAREA CONSTRUCTION SPECIFICATIONS L❑ Industrial �+O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I❑ Domestic/Private ❑ Gravel Pack ❑ Tracy F---'Type of Casin "—Specifications ,❑ Public ❑ Other ❑ Delta ( Depth of Grout Seal Type of Grouts ❑ Irrigation # ---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 601 a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION STRUCTION ❑ (No septic system permitted if',public sewer is ' 4 available within 200 feet.) Installation will serve: Resiflence Commercial �xOther Number of living units:= _ Number o4 bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg -f7 A I C>r F•+U= _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' I Method of Disposal ii _2 ; I Distance to Nearest .Well Foundation Property Line {LEACHING LINE M---No. & Length of lines aotal-length/size FILTER BED ❑ Distance to nearest: a Well Foundation Property Line SEEPAGE PITS [S-�Depth S Size Number SUMPS ❑ Distance to nearest: Well 'Foundation Property Line DISPOSAL PONDS ❑ '" t x s,/ 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 District. Home owner or licensed agent's signature certifies the following: ;'1 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."Contractors 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- of California." The applica u t call all r uir i s ctio s. Co ete drawing an r erse side. w SignedTitle: — 7 Date; FOR DEPARTMENT USE ONLY CA 1 r ..Application Accepted.by–..—a _._ _— - - _ ___ Date•—Z Area--M• Pit or rout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 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 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED$Y DATE PERMIT`NO. J INFO f CASH�4 + EH1&24{REV.70183} f1-R �r� � EH 1426