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Ts F. f } APPLICATION FOR PERMIT L �y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone'l209){2091 466-6781 T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,a . (Complete in Triplicate) , 4 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` r Job Address "i *�V.L+e�O tCt-2� city w Lot Size ; PM # �+ Owner's Name bnAJ -4C /"' ~Address irPhone Contractor ®Id/S' Address d ��/QO'OJLicense NoA Phone, Cq,SC%A TYPE OF WELL/PUMP: NEW WELL LlWELL REPLACEMENT ❑ DESTRUCTION ❑ _ k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 - i, ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Q Repair Work Done 1-1Type of Pump H,P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 5 O0') 0 Depth Filler Material IBelow 50') V ._l TYPE OF SEPTIC WORK: NEW INSTALLATION E. REPAIR/ADDITION ❑ DESTRUCTIO (No septic systet permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other tf - Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg tel.. CapacityNo. Compartments PKG. TREATMENT PLT. ❑ i f Method of Disposal Distance to nearest:- Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ''r" ""`�' — T Z Total length/size S t FILTER BED ❑ Distance to nearest: Well Fouhaation ^�'Property'Line SEEPAGE PITS 12 Depth Size _. t Number SUMPS ❑:. Distance to nearest: well Found tion Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will'be-dohe:io,accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San-Joaquin-Local-Health`Di`st�ict. "" '�-a 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."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." Th plica st call for fl req d in ctions. Complete`drawing on reverse side. X Signed X TitleDate: �! FOR DEPARTMENT USE ONLY Applicaiion Accepted by lo Date (4 7 Area Q'3-r Pit or Grout Inspectio ate Final Inspection by � Date Additional Comments: rov 10 I&S y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. r + EH 13-24 EH 14-26 1REV.i i a s1 O Q 5