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' � 1 I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone Q091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED :1 v10 zr (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 1 made in compliance with San Joaquin County Ordinance No.549 for sews or a No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /lf� y j Z Job Address 1w, City 5�� Lot Size tJ �` 'PM Owner's Name A Y\- 4k 1t-i 9 Address Phone P Contractor Address IT License No. L'7 '9 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1J r DISTANCE TO NEAREST: SEPTIC TANK h0 ke. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL All!X-e' PITS/SUMPS, te_ C? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial Sd.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing vee– Specifications r Fl Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout XIrrigadon {��_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 11 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIRIADDITION ( 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Y Distance to nearest: Well Foundation Property Line UtACKING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to clearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line DISPOSAL!1PONDS ... ...,❑ t- 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 Diltrict. 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 call for all re wired inspections. Complete drawing on reverse side. 44 Signe X r Title: _ r` C = 5 r Date: FOR DEPAtRTMENT USE ONLY �{ C� Application Accepted by Date / r��" / 0_ Area_13 o �- - 7 Pit r Grout I pection , Date Final Inspection by— —" �3ate--- Additional Comments: ❑ Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant --Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEEY AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. INFO y�y r +.EH 13-21(REV.t/H5) l EH 11-28 �, 1/ 1 f %D 16—r O —`Z01 1Z0 f f V r V I