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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone !2091 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. I B1 Job Address 9_65ToaA- Cit. Lot Size PM Owner's Name n R77 PMOI Address �L�,� L J ' LL�LPhone Contractor + A dress 6&tdE2291License hone TYPE OF WELL-/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM RYPAIR ❑ 0 HER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. PROP. LINE OO FOUNDATION AGRICULTURE WELLI�� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /- ❑ Industrial ❑ Open Bottom ❑ Manteca bia. of Well Excavation Dia. of Well Casing ,r .Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications q M Public Cl Other (� C-1 Delta Depth of Grout Seal Type of Grout tv I I Irrigation //' Approxi Depth I 1 Eastern Surface Seal Installed by ,� Repair Work Done �-�"fype of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION 1.1 DESTRUCTION I 1 INo septic system permitted if public sewer is { available within 200 feet.) Installation will esidence Commercial_ Other 9 Number of living units: of bedrooms Character of soil to a depth of 3 feetF Water table depth SEPTIC TANK ElType/Mfg Capacity � No. Compartments t PKG. TREATMENT PLT. ❑ ( Method of Disposal 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 II SEEPAGE PITS I I Depth + Size: ' Number SUMPS ❑ 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 rules and regulations of the San Joaquin Local Health Diltrigt. 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 fd become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performancefof'the work,for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applican u call for all req ' nspectio s.rompleia d 'wing/on4averse side. lir Signed X Title: 4 Bate: FOR AEPARTMENT USE ONLY Application Accepted by Date A a f Pit.or rot spection by Date -- Final Inspection by Date~ Additional Comments: �lt� r d �� Y� �� / /to ❑ Stk 466-6781 El Lodi 369-3621 C Manteca 823-7104 ❑ Tracy 835-6385 d/J 1:71e— Applicant - Return all copies to: Enviror mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO �AMOUNT DUE AMOUNT. REM[TTED CK RECEIVED BY DATE PERMIT'NO. +.EH 13-24 1REV.i/x 57 1o�av -- ISO 00 S EH t4-2B ° t r `l WWW co I l