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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Rules and Regulations of the San Joaquin Local Health District. b �f f / g 3� Job Address /p�ftj b�/tP d{.0 City ' F F Lot Size PM z-..— --- -- '-- - Phone Owner's Name,: Address - Contractdr�[f1dG�Q Address License No. kxv, Ph"obgR 0s�- 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 L_"=AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing's Specifications (-I Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation —.Approx. Depth�I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction—E]--Well-Diameter Sealing Material Itop 501 Depth I ler Material Melo -50') TYPE OF SEPTIC WORK: NEW INSTALLATION IaREPAIR'ADDITION DESTRUCTION i l (No septic system permitted if public sewer is available within 200 feet.) ! Installation will serve: Residence= Commercial T .'Other - f Number of living units: 01 Number of b rooms, Q.Q. Character of soil to a depth of 3 feet: —Water table depth SEPTIC TANK .❑ Type/Mfg F Capacity -No. Compartments PKG. TREATMENT PLT_. ❑ "' Method of Disposal rY' ► Distance to nearest: Well Foundation Property Line LEACHING.LINE No. & Length of lines total length/size x FILTER'BED ❑ Distance to nearest: Well 71�. Foundation "ID 'f Property Line r tf SEEPAGE PITS 1 3 Depth _ � ___ Size r Number SUMPS Distance to nearest: Well_fQ Foundatjon 11J r 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 taws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfor ance of tfie work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." Al °. .,The applicant st call for Ire wired inspections. Complete drawing on revers ids. - Signed X _ ! Title: ,�. .. '` l _ Date-�� • `a� FOR DEPARTMENT USE ONLY ! ^� Applic t' n Accepted by Z,/ °"+ Date,. y / r Area r P' rout ns c Ion by Date tFinal,Inspection Lb 0. Date5-?v-se Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 f' ❑ Manteca- 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental-HealiK,'Parrn t/5er'vi6g 1601�E, Hazelton Ave.;iP.O. Box 2009, Stk., CA 95201 F � � FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y- DATE PERMITNO. INFO CASH + EH 13-24IREV-�/K51 EH 14-28 .!.., ��S g 1.1.1i 4"l�ta"T