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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT } At 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 (Complete 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 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 0� O !r_e City I'o Lot Size PM Owner's Name 4 rs G Addr[e�ss G 0_ Phone �G 1. lr F . — �� "^ ,' Contractor ° mil 75 J D Phone .Gr Q Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 0EST9LICTION ❑ ' PUMP INSTALLATION"❑" SYSTEM REPAIR ❑ OTHER ❑" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .— FOUNDATION INE .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.;of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public CI Other n Delta Depth of Grout Seal ,Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 f Depth Filler Material (Below 501 ' TYPE OF.SEPTIC WORK:`"NEW INSTALLATION-14-REPAIRYA"DDITION ESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) s Installation will serve: Residence Commercial_ Other ' ' Number of living units: I Number of bedrooms Character of sail to a depth of 3 feet: 4j7� —Water table.depth SEPTIC TANK C Type/Mfg Capaclity—r No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal v Distance to nearest: Well Foundation Property Line LEACHING LINE —No. & Length of lines 60 Total length/size d FILTER BED ❑ Distance to nearest:- Well._ FoundationTProperty Line SEEPAGE PITS i I Depth Size - `5 r Number ,dation y SUMPS L1 Distance to nearest: � '1iVell :.n. 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. F Home owner or licensed agent's signature certifies the following: "1 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,_1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all r2quired inspections. Complete drawing on reverse;side. Signed X� ,3d Title:" f _qQ4, Date: FO DEPARTMENT USE ONLY ,�y 7 i Application.Accepted by Date " .a�t/ a Area i ✓ j Pit or Grout Inspection by 'Date Final Inspection by Date 11a , Additional Comments: ❑-Stk 466-6781•--- -E]--Lodi 3&9=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 95201 T INFO AMOUNT DUE AMOUNT REMITTED C$H 'RRECEIVED BY —DATE T � PERMIT'NO. +.EH1324(ppV.IiKs) 76.q f I EH 11-28