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i APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR 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 les and Regulations of the San Joaquin t Local Health District. Job Address City of Size PM I Owner's Name _ dd ess I�%//J�/ W � !/[i U _ Phone 7 Contractor @dress License No. S QT`S Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE ' FOUNDATION -- AGRICU L-TUBE WELL. -- OTHER WELL PITS/SUMPS; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS : ❑ Industrial) ❑ Open Bottom , ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificatians� ('1 Public Cl Other F.1 Delta Depth of Grout Seal Type of Grout I I Irrigation., Approx, Depth I i Eastern Surface Seal Installed by _ s -Repair Work'Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ; Sealing Material Itop 501 Depth Filler Material jBelow 50') TYPE OF SEPTIC WORK:,- NEW INSTALLATION 1.1 REPAIRJADDITION. DESTRUCTION I I (No septic system permitted if public sewer is ` j available within 200 feet.) tF Installation will serve: Residence_ Cor>Qercial___W_ Other Number of living units: Number of bedrooms :5„ .y r f Character of soil to a depth of 3 feet: ' Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity r No: Compartments PKG.-TREATMENT PLT. ❑ ,� r !Method of Disposal s i Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length-of lines f Total length/size FILTER BED ❑ Distance to nearest:" We Foundation Property Line SEEPAGE PITS 11 Depth Size Number 1!F SUMPS ❑ Distance to ne re t: Well ° Found on Property Line 6 DISPOSAL PONDS ❑ ?� �tv— �-��}� 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 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 taws 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 applic t call for allctions. mplete drawing.on reverse side. ` Signed X S /l _ Date: r FOR DEPARTMENT USE ONLY Applic nn -ccepted�bey � f Cl�L� r`' 1 Date r Area Z—Y Grduf inspection by `'Date�r�4 6. o— ----Final Inspection b � D to Additional Comments: ��GL�Ll1 LY�CI��' - �v8•'P ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-Lodi 369-3621 Manteca 823-7104 Tracy 835-63855 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 5/0i--17 FEE _ INFO _AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE p PPERMn'NO. �� + EHS3.241REV.tiN51,....--� .-...��,�UE \. tJ�sj'.. EH 14-29 ']_