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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 3 YEAR FROM DATE ISSUED I (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 0* Obs-/&0 "D7 0[ =/70-1 1 I Job Address Q City Lot Size tr X jf0V� PM Owner's Name • Address fes! Phone Contractor tl Address ' cX:r�l1 �/�'� E ELicense No. aPhone TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ orf � t PUMP INSTALLATION ElSYSTEM REPAIR 11 OTHER )e 43� 0 ZOO d~ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _�Ir464 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation of Well ening ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -S4=fisattans i"] Public F� Other ❑ Delta Depth of Grout Seal >_µpe fent _ I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Q Repair Work Done LJ Type of Pump H.P. State Work Done i� �t[,� Well Destruction E] Well Diameter Sealing Material (top 50') P r &r°.t1 its Depth Filler Material (Below 50') �frLGOUjtfP�vt'e� __ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 o1 Disposal C7 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 I Depth Size _ Number SUMPS l3 Distance to nearest: Well 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 f rules and regulations of the San Joaquin Local Health Dstrict. 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." f! The applicant st aII for all r re i s ctions. Complete drawingon r erse side. 1 # Signed X Title: �e Date: FOR EP RTME T USE ONLY Application Accepted by Date .– �J ^ tl Area Pit or Grout Inspection by Date Final Inspection by Date v Additional Comments: f ❑ Stk 466-6781 L1 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CA5H ^�� E + EH 13-24 IREV. /x 5) Q O O �'C EH 14-28 VJ _�/I