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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 (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. p G ,, , . _ __�1 Job Address /ld 7� �• / �*,�{/'�` �I+��-�- GCCity�j a-;" -� Lot Size C/ PM Owner's Name ' ,/�icv"a•�+`�'1 Address /�/t 0/'�7��(0'i/1-(9 /�`'�-N Phoneme 6 Z-ry/�7yB' Contractor /:!,a& /A,,�Address 137) r/'""""• ""'� License No/ 2373 Phone3 C TYPE OF WELL/PUMP: 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Da. of Well Casing ' ..2-6omestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta_ Depth of Grout Seal Type of Grout \ ❑ Irrigation _1Approx. DeRRth ,,�❑ Eastern Surface Seal Installed by �n^ Repair Work Done ❑ Type of Pump J.1 H.P. 3 State Work Done P"Ag Well Destruction ❑ Well Diameter dd Sealing Material (top 50') a- Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2D0 feet.) Installation will serve: Residence_ Co irmrcial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments «. PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Wall 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 California." -• The applicant s1 cell for all required "nspections. mdete9drrawing on reverse side. Signed X T'( tle: Date: I^�,— FOR DEPARTMENT USE ONLY Application Accepted by Data Area a Ph or Grout Inspection by Date 'J/� Final Inspection by Date Additional Comments _ �" ❑ Stk 466-Ml Lodi 309-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 f,•AQ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Z / V f INFO FEEAMWNT DUE AMOUNT REMITTED CASN RECENED BY DATE PERMIT'RO. T f r .EH ty 1}z�la .pie s1 14 14]6