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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 �y 87� /r'• �JL.g'1 / % O y/� City Lot Size r� �Cl/PM �p Owner's Name ire �� . Address �a 8`r/ /✓./r /�GA.' Phone e` —�a7 Contractor L' Addres icense No.1116021/O 9CS or TYPE OF WELL PUMP: NEW WELL @T WELL REPLACEMENT ❑ DESTRUCTION ❑ r \ PUMP INSTALLATION"❑"- "'- St/STEM REPAIR 0 - OTHER ❑ P. LMON 1 _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROINE _ •W✓vllll FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ell ❑ Industrial ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack 0^Tracy Type-off Casing "-7 - Swificatioris ❑ Public Opthyr ❑ Delta Depth of Grout Seal 8S 'r T Grout ❑ Irrigation ?09X.4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system Permitted if pudic sewer i available within ZW feet.) Installation wl Residence_ Commercial Other ✓ Number of living units: ber 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS O Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Distript. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pemdt 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 subcontracting 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 must call for all required inspections. Complete drawing on`rev�erse side. ^7 Signed X W � Title: d� ! , Date: - �! FOR DEPARTMENT USE ONLY Application Accepted byDace V , Area_1 Pit or Grout Inspection by Date ` Final Inspection by�� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 83.546385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO 1 CASH (fit S 91 0 EH 1]-N IREV.it e s) �� V r /S� -:t—P7 14 EH 1429