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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-Ml 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 88 City G Lot Size PM Owner's Name Com'/ �" t'�� Address V Phone ` ^�a� Contractor G` Address ' icense No, 36Qx110 9 Phorl _ TYPE OF WELL PUMP: NEW WELL Fr , WELL'FIEPLACEMENT. ] DESTRUCTION ❑ 4� PUMP INSTALLATION-1-1 YSTEM REP OTHER ❑� f'tQAf p,\ TO NEAREST: SEPTIC TANK _ ' ,SEWER LINES DISPOSAL FLD. ROP. LINE. \ DISTANCE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI ❑ Industrial ❑� �0 an Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private CwGravel Pada "%%[--,Tracy Type oof C`asirigt �^'Specificatioris• G Public Gptn� ❑ Delta ;5 Depth of Grout Seal S�<r -� T pe of Grout G Irrigation ;20�1091�pprox. Depth ❑ Eastern`r Surface Seal Installed by 9:� � ^ Repair Work Done ❑ Type of Pump H.P. State Wo Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 -3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION n- (No septic system permitted if public sewer is available within 200 feet.) Installation will3 . Residence— Commercial t Other Number of living units: ber of bedrooms I ,+ Character of soil to a depth of 3 feet: { Water table depth r SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well) Foundation Property Line I LEACHING LINE 7 No. & Length of lines � Total length/size ' FILTER BED Distance to nearest: Well Foundatlon Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line s DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application andithat 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.�..;1 ;,�� Home owner or licensed agent's signature certifies the following: "I Certrfy,that in I - pefformance 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 applicant must call for all required inspections. Complete drawing an reverse side. Signed X_-'-jyn,� Title:. � !-f-__ -_ Date: ! 7 FOR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by., n / �_ Date Additional Comments: L Stk 466-6781 ❑ Lodi 369-WI ❑ Manteca 823-7184 ❑ Tracy 835-638,5 Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO SAM . EH 1124 IREV.I/a 51 / ( / �'"✓((l-7 `v EH 1426