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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 11601 .E HAZEL—i ON AVE., STOCKTON, CA y 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 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. ' Job Address 3 �3. (5=7 .-W (5,6 E/p.�' U City 5Va C VY'I?ot Size 0 PM Owner's Name �' �.L.0�S'-'1'/-/-/dAddress 45310-3 ,C U>EA E t/ Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER,L•INES1,�L�_ ^�> DISPO,S_AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ 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 N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU 10 ( o septic system permitted if public sewer is j - ailable-within-2004eet.i Installation will serve: Residence_ Commercial— Other , Number of living units: Number of bedrooms JGt ra��'ruh!` Character of soil to a depth of 3 feet: ( Water table dept/h n� SEPTIC TANK El Type/Mfg } i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to!nearest: Well Foundation Property Line I LEACHING LINE ❑' No. & Length of lines] Total length/size FILTER BED ❑ Distance to!nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth f I Size Number SUMPS ❑ Distance tol nearest: "Well Foundation Property Line DISPOSAL PONDS ❑ 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 District. I Home owner or licensed agent's signature certifies the following: "Icertify 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 compe)lsation laws of California."Contractors 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. i The applica t us o all uired inspections. Complete drawing, n idg Signed Title:. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date .7 Area Q� Pit or Grout Inspectio y Date Final Inspection by r/. ��•f�[n� � / �d Additional Comments: Wh2 otf 5- lCS /l _s 7Z F-1Stk466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE.- AMOUNT REMITTED �aSA RECEIVED BY DATE PERMIT'NO. + EH 1324(REV.1/65) 3 EH 14-28 • �o c0 � R7