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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I'.. Telephone 12091 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED r (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 Conty 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 City Lot Size ?Q�/1C'f PM Owner's Name–Da–de /�J gz:�" Address 60.X Phone /K7 Contractor �y Address tr+.- License No Phone TYPE OF WELL/PUMP: 7._ NEW WELL WELL REP-LACEME T ❑ DESTRUCTION LJ � � jE ";:7e, PUMP INSTALLATION�$� '; SYSTEM REPAIR ❑ OTHER'❑ ff �y.r DISTANCE TO NEAREST: SEPTIC TANK ll SEWER LINES,- " DISPOSAL FLD. PROP. LINE'�6 F FOUNDATION AGRICULTURE WEL ` ~ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 16% Domestic/Private ❑ Gravel Pack ❑ Tracyi" � _ ;% Type of Casing_-A/� Specifications /(y�o f Public ❑ Otherx"� Li Delta Deptti of Grout Seal `�iLT"� �� Type of Gf6ut I I Irrigation g j .Approx. Depth -I ! Eastern S u rface Seal.Installedd by SP _ Repair Work Done c Type of Pump H.P. __.._.y7 State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth �. Filler Material (Below 501 s s TYPE OF SEPTIC WORK: NEW INSTALLATION 11. REPAIR/ADDITION 1.1 DESTRUCTION I 1 INo septic system permitted it public sewer is �. "r available within 200 feet.) Installation will serve: Residence iCommercial— Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i ,w Water table depth SEPTIC TANK ❑ Type/Mfg l Capacityoe No. Compartments PKG. TREATMENT PLT. ❑ TE a 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 I ] Depth 1 Size Number _ SUMPS Ll Distance to nearest: Well Foundation - Property Line o 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: '9 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 ired i spe�nsomplete drawing on reverse side. i Signed Title: Date: �< < FOR DEPARTME USE ONLY Application Accepted byAit/ Date Area V Pit or Grout Inspection by Date / -9� Final Inspection by /1�Tj'L Date r _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environrriantat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 35201 t FEE INFO AMOUNT DUE t AMOUNT REMITTED EK-7 RECEIVED BY ' DATE: PERMITNO.. CASH +.EH 19-24IREV.rix51 * - Z�11u 1 EH 1428 ,1