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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. `� _ Job Address. � , l i�.J- ?>�t 1��11J 1� C?�• City ti Lot Size PM Owner's Name�� j b r14I1 K Address (,-,)I N,• Phone Contract ,-, " Address `C, (�c'/\ / lyt4f[ License No-317 Z Z L Phone 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public fl Other 1-1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ler Material (Belo 50') TYPE OF SEPTIC WORK. NEW INSTALLATION IEPAI '/ADDITION LK DESTRUCTION I I (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence L Commercial Other Number of living units: —41— Number of �edro ms Character of soil to a depth of 3 feet: /'��tZl: ->�Cis\ Water table depth C) SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i r'J LEACHING LINE El No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line • SEEPAGE PITS 1tr/Depth . Size Number r + i SUMPS I Distance to nearest: Well 100 t Foundation t4 Property Line J 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 m' t call for^reqrecl inspections. Complete drawing on reverse id f , Signed X 3 'x t/L� Title: _ \ ,1 - Date:�? 1 /��' \J FOR DEPARTMENT USE ONLY , /A/pp�lication Accepted by Date ti Area k /Payor Grout Inspection by Gy Date ?y rx'Final Inspection by' Date /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 A 1t FEE AMOUNT DUE AMOUNT REMITTED CK tt RECEIVED BY DATE PERMIT NO. INFO CASH EH 13.24(REV.i-n51 �/ �/gg, 13 1? EH 14-26 �� - ( FS J