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1 ,(1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 C - City , Lot SizePM Owner's Name Address Address 1+7Phone }8 Contractork44 +C AAN Address � � �7��14+uQ License No. y13 z03 Phone-2ce-6?752 8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION)\ SYSTEM REPAIR ❑ OTHER L1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION �" -;AGRICULTURE WELL, t OTHER WELL PITS/SUMPS INTENDED USE—TYPE OF WELL—PROBLEM AREA.60NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing I ❑ Domestic/Privayte 171 Gravel Pack ❑ Tracy Type of Casing Specifications F Public �4i# CS171Other n Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation= k.Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done ❑ Typeof�Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filler Material (Below 50') ^ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION,I I DESTRUCTION I I (No septic system permitted if public sewer is �. available within 200 feet.) Installation will serve: esidence____ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity �� No. Compartments { PKG. TREATMENT PLT. ❑ fi Method of Disposal L I Distance to nearest: Foundation 1 Property Line LEACHING LINE ❑ No. & L th of lines Total length/size FILTER BED ❑ ante to nearest: Well _ ndation Property Line SEEPAGE PITS i I Depth Size """•"*^Number SUMPS ❑ Distance to nearest: Well i Foundation N Property Line l" DISPOSAL PONDS ❑'A.+. 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 DiMrict. Home owner or licensed agent's signature c6r ifies.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." kt y ' The applican m t !1 for all`ieq !r i pections!Complete drawing on rev a side. ' r Signed X Title: Date: D� �� FOR DEPAR MENT USE ONLY ApplicatiojAccepted by _ Date � �� Area Pit or Grout Inspection by Date Final Inspection by ..» Date! a� Additional Comments: ❑ Stk 466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. i INFO �.EH 13-24IREV.1/H51 ��, �/ �, (� f 7 ✓�� aO � EH 14-2e