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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 •&_?O 0 KO& ../ L.(J (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. 1662 for well/'pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address - <of?/J�q /_ C`ity�P Lot Size ! PM Owner's Name B� '� �-! Address'7"d / 0 i+tiy-�.CJ mss/ .144 Phone (, Contractor's Name" License No. AQ D-3 7 3 Phone3(0 TYPE OF WELOPUMP: NEW WELL F1 WELL REPLACEMENT ❑ DESTRUCTION ❑ e PUMP INSTALLATION ❑ SYSTEM REPAIR Er OTHER ❑ '14j DISTANCE TO NEAREST: SEPTIC TANK SEWER EINES 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 , ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �. Q Irrigation --Approx. Depth_'❑ Eastern Surface Seal Installed by 0 Repair Work Done El Type of Pump H.P. a d State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Meterial'Welow 501 rb "?TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 1 '• SEPTIC TANK-- Type/Mfg CapacityNo. 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 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 m 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 Califom"The applicant in all r all re inspections. ompletqee�d�rrawing ,J(ayve/rsee aide. Signed X —�'�✓(� !'z"Title: '"t !z .. Date: J tel! FOR /DEPARTMENT USE ONLY Application Accepted by DateS �y61 `y Area`r Pit or Grout Inspection by Date T� Final Inspection-by '// �`^'� Date Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca -623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.