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� e APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED`' (Complete in Triplicate) .m 5.., .. - i t .. - •-T y ,_1 41 Application is hereby made to they 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. "rw$. �i �7 ty ":'a' Jab Address ' � Ci Lo Size '' � i'D -PM Cp_ ame "dress' Phone Contractorc � --Address�7,�- ��/��sv�Qi icense No&X21'1 Phone - r�fd`d TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT'171 DESTRUCTION ❑ PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ✓7J' DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE - - FOUNDATION=- AGRICULTURE WELL 3\ ;OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Z Manteca Dia. of Well Excavation Dia. of Well Casing kT Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C./) ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout f c �J� ❑ Irrigation --4pprox.iDepth ❑ Eastern Surface Seal Installed by iw--� ' Repair Work Done ❑ Type of Pump H.P. State Work D ne Well Destruction ❑ Well Diameter Sealing Material (top'501) Depth Filler Material (Below'501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 {" ` � 1 Character of soil to a depth of 3 feet:� Water table depth�. SEPTIC TANK ❑ Type/Mfg. J Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' (' �'1; Method of Disposal Distance to nearest: Well Foundation 1 Property Line LEACHING LINE ❑ No. & Length of lines 'Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F { I SEEPAGE PITS ❑ Depth `, Size Number. SUMPS ❑ Distance to nearest: Well Foundation Piopegy 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 lawsws ari—d " rules and regulations of the San Joaquin Local Health District. I (--r-•�k �"k Home owner or licensed agent's signature certifies the following: "I certify that in the performance of ttie 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 shaNiemplci persons subject to workman's compensa- tion laws of California." E I T The app:Wu/sc t all I required inspections. Complete drawing on re e``side. h 4 1 Signed = `" ` -JTitle: y �^� _ ._ Date:. / FOR DEPARTMENT USE ONLY ' �/ Application Accepted by v f Date / —1 T '�� Area Pit or Grout Inspection by Date Final Inspection by Date — S` Additional Comments: = ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 ! 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 CASH RECEIVED BY DATE PERMIT NO. INFO _� ( �y 4 + EH 1324 1REV,i/e 51 73 `�� 5C,^�( d` EH 1426