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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 t 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. a a Job Address City Lot Size,93 &� PM nneOwner's Name l� Address -,I, W "" ph Contra ctdr Na Address Ro ,`Qox,, (g 7 License No., q(e Phone 0$` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (J,4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0, t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION ? AGRICULTURE WELL F 0 OTHER WELL PITS/SUMPS t� INTENDED USE TYPE OFWELL--"," PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation bia, of Well Casing ❑ Domestic/Private a` ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications .❑ Public ❑ Other ❑ Delta Depth'of Grout Seal .- Type of Grout ❑ Irrigation. ---Approx. Depth ❑ Eastern_ Surface Seal Installed by Repair Work Done �❑ Type of Pump H.P. State Work Done " F Well Destruction ❑ Well Diameter Sealing Materi.gHtop 501 Depth Filler-Material fBelow 50') E II r TYPE OF SEPTIC WORK: NEW INSTALLATION,gr REPAIR/ADDITION ❑—DESTRUCTION-E�-INo-septic-system-Oermitted if public sewer is 1 available within 200 feet.} Installation will serve: Residence Commefcial_ Other Number of living units: __/_ Number of bed roo 'A^i Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK Z- Type/Mfg ' Capacity tc0©a No. Compartments.:' PKG. TREATMENT PLT. ❑ � f Method of Dis osal 1 r Distance to nearest: Well Foundat on (C�7� Property Line S LEACHING LINE k"'No. & Length of lines. -:25 Q Total length/size © K s t r + FILTER BED ElDistance to,nearest: Well _.. Foundation I I? Property Line S SEEPAGE PITS F Depth rxt -. -Size T In r� party Line S ' Y 11 SUMPS ❑ Distance to nearest: Well�� Foundation Pro i 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, an rules and regulations of the San Joaquin Local Health District al 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 no 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." t The applicant mus all for all req ' d in pections. Complete drawing on reverse side. j 0 SignedTitle: V + Date9(0 FOR DEPARTMENT USE ONLY Application Accepted by Date Area } Pit or-Giout Inspection by Date CU inal Inspection by t Date f I'� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 104 ❑ Tracy 8356385 ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA,95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 1324(REV.t/857t`� t EH 1428 _7C5. cp / y c4 Ro -i I7�Z , 1