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I j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sari 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. 216 sAv>a: _ City �tr�C�r�rt Lot Size PM I Owner's Name ) [ �_�-,[[r� Address f-kf-m e+ Phone gff7 Contractor I Address License No. Phone ! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION EJ PUMP INSTALLATION C1 SYSTEM REPAIR © OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ GravelPack C7 Tracy Type of Casing Specifications 1 '1 Public ❑ Other I 17 Delta Depth of Grout Sea! Type of Grout _ I I Ifrigation _._Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 11 Type of Pulmp H.P. State Work Done_ \, Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material {Below 50') _ \ TYPE_ OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION I 1 (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 C Character of soil to a depth of 3 feet: ��y- -r—Ir' J. Water table depth SEPTIC TANK ❑ Type/Mf, Capacity No. Compartments PKG. TREATMENT PLT. © Method of Disposal Distance to nearest: Well Foundation _ Property Line i LEACHING LINE ❑ No. & Length of lines rte` Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size _. x um r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 'I I hereby certify that I have prepared tAis 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. r 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, 1 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 he performance of the work for which this permit is issued, I shall employ 1IJI P p y persons subject to workman's compensa- tion laws of Califo is-" p ' The applicant m.st I r al Si € required i cti ns. C�t ing on reverse side. i gned X L r itle: ^ _ '' Date: 69_? j F fi DEP TMENT USE ONLY I Application Accepted by �ab- - f ' Date 1 J Area Pit or Grout Ins pection by Date Final Inspection by t r f'i •� pate Additional Comments: zit ��! ❑ Stk 466-6781 ❑ Lodi 369-3621 E3 Manteca 823-7104 ❑ Tracy 6385 �r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 FEE AMOUNT DUET AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ; +.EH 13.24(REV.r/n 51 F _7 I t - EH J4-29 I (