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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 �},�,�� l� /�, Job Address iJ1'� (?`lJ_/r/11.r� ��s/�� ZAW City Lot Size PM Owner's Name _li�p �y�f _._ Address �/70,r�• /1� G �[.c �hohe �l51 ContracIor6MM 4 FXV1Zegfr�( Address _Y096 /Zif 49Air_ 14,9P e01W19&License NoC57Sr3N3U3 PhonA15 071 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER n DISTANCE TO NEAREST: SEPTIC TANK LR_ SEWER LINES DISPOSAL FLD. _ PROP. LINE / FOUNDATION AGRICULTURE WELL Mf OTHER WELL �� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing__ Specifications �jfJ►7 Fy80 I"1 Public Cl Other n Delta Depth of Grout Seal 50 K[irsfoYc2 lP Type of Grout 14 f"�Iu 1, 40 Approx. Depth KEastern Surface Seat Installed by :Z&R? 19Z it�D�rJ1�IR/SJj/C __ Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ( I Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK NEW INSTALLATION I t REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is avai ble within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedroo i Character of soil to a depth of 3 feet: - Water table depth 1� SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposa Distance nearest: Well Founda n Property Line LEACHING LINE 1-1 N . & Length of lines Total length/size FILTER BED [1 istance to nearest: Well Foundation _ Property Li SEEPAGE PITS I I Depth - Size Number - SUMPS l I Distance to nearest: Well Foundation Property Line DISPOSAL POND (� 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, 1 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 mus all for all re9yy'r Ainstions., drawing on reverse side. Signed X Title: FOR DEPARTMENT USE ONLY / Application Accepted by fes---- --- Date . //Y Area Pit or Grout Inspection by _ Date 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 55201 FEE AMOUNT DUE AMOUNT REMITTED II RECEIVED BY DATE PERMIT NO. INFO CASH CK r EH 1346 IREV.r i n sl3 EH 14-20