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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT p 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 t PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ,' ! (Complete in Triplicate) j 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 _/ / Sb G � f E� City 40,g2t Lot SizeK o PM Owner's Name PDl_ T/sem0_,6dVy4A Address 7 i� 919 C �QoXI��' Phone �0 x Contractor Dt1Lay<Gp Address 2eoo e". License No3Y01'?1J Ph,,aO —1472 TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION 'i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_ PROP. LINE `\ I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^� D Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other Cl Delta Depth of Grout Seal Type of Grout i I Irrigation _.-Approx. Depth [ I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I ] DESTRUCTION I 1 INo septic system permitted if public sewer is r available within 200 feet.I Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 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 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 became 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." / The applic t m �stcall if r quire ins tions omplete drawing on reverse side. Signed X Title: �� 2 � a Date FOR DEP RTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: c ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ danleca 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 f INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. +.EH 13-21(REV.1i85) EH 1I-29