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APPLICATION FOR PERMIT 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 Sart Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with Sari 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 -,iO5+ o ,5,6 � (,y _ City Lot Size PM Owner's Namelg C_�' __i _ Address '3_'_ Q Phone sTit-y tl` �/ Contractor Address/ql�� (�RT�ltense No.21�Phone-362 TYPE OF WEL /PUMP NEW WELL 17WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION?S SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ___ DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT$/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V Domestic/Private O Gravel Pack El Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_- I 1 Irrigation —_Approx. Depth i I Eastern Surface Seal"Installed by Repair Work Done U Type of Pump _CLLA—_ H.P __. X Z" State Work Done.TAI Well Destruction ❑ Well Diameter _ Sealing Mate al Itop 50') Depth _ Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is t 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 _ SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ T ❑`No. & Len Length of lines Total length/size -- - — LEACHING LINE g 1 ❑ Distance to nearest: Well Foundation _ Property Line _�--- FILTER BED T— -- - l I Depth — Size Number -- -- SEEPAGE PITS SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ — nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application a 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: certify that s the performance sauce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.'" The applicant ust call r all required inspections. Complete drawing on reverse side. 90 Signed X_ ___ --- - — Title ._ — Date: - — R DEPARTMENT USE ONL!!�� - tel i Date�� Area Application Accepted by Date Final Inspection b D Datat Pit or Grout Inspection by - — \�i_'�— s r Additional Comments: — ❑ Stk 466-6781 C7 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 CK Jl RECEIVED By DATE PERMIT"NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO — r EH 13-241REV +INS) � `� C _� f1 /��,� 10-N05 '�� Q