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APPLICATION FOR PERMIT `ft/ 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �7 c ,f ,z J 'J Job Address //j / < ,5 6 EA„> >!s - '�/ city&q irJ.�7c.W Lot Size pM Owner's Name &A�1 l �� Address Z776-6 F_� / �✓+ Y pho Contractor Address H'"1z icense No.nakG 3 phoneq/ / TYPE OF WELL/PUMP: NE WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 2-- -5,41D 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 ndustriat ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications M Public QW40ther ❑ Delta Depth of Grout Seal 11515" Type of GrouU&_WA� 4 I I Irrigation SCDApprox. Depth 1 I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump -Q H.P. State Work Done_ Well Destruction ❑ Well Diameter ry Sealing Material (top 50') Depth 3� Filler Material (Below 501 .� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms V 1^I Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Distance to nearest: Method of Disposal Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of linesr Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 to workman's compensation laws of California." Contractors 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 applic tall required inspections. Complete drawing on reverse side. Signed X I for Title: Atex Date: EP TMVIT USE ONLY Application Accepted by — ��''�� Date Ar Pit or Grout Inspection by Dated Final Inspection by Dot CJy' Additional Comments: ❑ Stk 466-6761 ❑ 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 FEEAMOUNT DUE AMOUNT REMITTED INFO RECEIVED By DATE PERMR NO. ♦ EH 14f11aEV.vx m �-7 I \- - /�� QQ FH lla3 - .. -