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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 4& 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. i Job Address ��3r�. �L� �e,� .ci / � City Z Lot Size PM Owner's Name /�-GC�w �� Address Phone r Contractor Address SUSAvens rC� Phone License No. TYPE OF WELL/PUMP: NM WELL LlWELL REPLACEMEN DESTRUCTIONS' `. PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ 7S�_ SEWER LINES DISPOSAL FL PROP. LINE (�� FOUNDATION AGRICULTURE WELL OTHER WELL O _ PITS/SUMPS } I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSV El Industrial El Open Bottom E] Manteca Dia. of Well Excavation /,� � Dia. of Well Casing �F • Domestic/Private X Gravel Pack ❑ Tracy Type of Casing oac Specifications Ap ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surf ce Seal Installed by ... Repair Work Done ❑ Type of Pump - 4 1 H.P. State Work Done Well Destruction El Well Diameter r1 Sealing Material (top,50') _. Depth. /�!l� Filler'Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑, DESTRUCTION ❑ iNo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms�R Character of soil to a depth of 3 feet:';. _ Water table depth SEPTIC TANK.l ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 0 Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 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 tail for all required i pec ions. Complete drawing on reverse side. Signed X Title: Date: kk E. FOR DEPARTMENT USE ONLY I Application Accepted by / Date Area Pit or rou Inspection by at `moi al Inspection by ��Date• r Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA Ssx FEE INFO AMOUNT DUE AMOUNT REMITTED LC"CASH RECEIVED BY DATE PERMIT NO. + EH i3zaiREv.,iHs> . 1� , r/ Seo—tl�� ' EH 14-ZB r