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APPLICATION FOR PERMIT An SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA b 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 Joaqun Local Health District. C � CO Job'AddressN City-�Y.._%9 __ Lot Size PM nn Owner's Name ViTo Ayv/0 Address ' �5 - - Phone Contractor's Name CfJ/ /� �,—license No�'"— Phone 3 � l TYPE OF WELL/PUMP: NEW WELL ❑ -WELI.REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ��.. % ,SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - FOUNDATION AGRICULTURE WELLS OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SRECIFIeATIONS ❑ industrial J ❑ Open Bottom ❑ Manteca Dia. of Well-.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___4pproz. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Elm Type of Pup H.P. State Work Done N Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) lirstallation will serve: Residence_/_ Commercial_ Other Number of living units:_/_ Number of bedrooms l Character of soil to a depth of 3 feet: SA `c Water table depth '9 e SEPTIC TANK ❑ Type/Mfg Pym Gas Capacity No. Compartments 1;7- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line /.,� � p LEACHING LINE No. & Length of lines d �n0 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation /a Property Line S SEEPAGE PITS ❑ Depth /�` Size �S'.Y��X/� Number , i t: c'. �'- S 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 District. 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."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." The applicant must II for all required inspections. Complete drawing on reverse side. Signed Title: Date: / ;jS• FORD ARTMENT USE ONLY �] 2 � / Application Accepted by Date `_.."Area—, Pit or Grout Inspection by Date Final Ins ectian by T Date Additional Comments: 10�� ❑-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. INFO CASH :+EH 1324{REV.14/83i .— - EH 1428 J