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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON,AVE., STOCKTON, CA Telephone (209) 466-6781 + PERMIT EXPIRES '!„YEAR FROM DATE ISSUED IComplete in Triplicate) 'i 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 Cuunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I x-4— rr-5+ld SocrrkWet a C00W � 1 rU 5WS City �I Lot Size ��'1 PM�'•r 3 Job Address �ttiryt� ��Zl� 9 F .sr�a� Owner's Name• QJDA,Q 4MgP AddressZ Phone-%030-19 — 6Z5 Contractor S• r Address �' '•"G lL�Cense iVp•.L-� �� Phone TYPE OF WELL/PUMP: NEW WELL I❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION i❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK '}�OG►JIL SEWER LINES >I 0 0 f+- DISPOSAL FLD.— PROP- LINE FOUNDATION AGRICULTURE WELL MR LL7�JPITS/SUMPS 'cf` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONNS ❑ Industrial C Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing Type of Casing r Specifications D Domestic/Private ❑ Grrra'�vel,Pack Tracy TYP g I f.l Public 5�41AZ4{''0/441 1-1 Delta Depth of Grout SType of Grout I 1 litigation Approx. Depth f'I Eastern Surface Seal Inst - Repair Work Done L7 Type of Pump H.P. rk Done Weil Destruction C Well Diameter Sealing Material (top 50'1 }.. r �](ilDllr;{�ftit' j(ps �'3 Depth Filler Material (Below 50'i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRailseptiable w shin m ffma ed if public sewer is 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 A PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: well Foundation Property Line N I LEACHING LINE ❑ No. & Length of lines 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 i 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 reguiaiions of the San Joaquin Local Health District. Home owner or licensed agent's signature cerlifies 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 applica t tail for all requi d iq ec ons. Complete drawing on reverse side. Signed X Title_ , — Date: FOR DEPARTMENT USE ONLY Application Accepted by `�—� F� / Date �`- - r._ �- - Area �1 r Pit or Grout Inspection by Data 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 95:01 FEE AMOUznp NT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO • EH 13-24(REV.1 r n so � �.r /�`�_Jr EH 14.26