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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (200) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �c .��d S -7 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. j/A �[� rer'uer V c G het >¢Ncf e?h o V4F1W. �pc�l� Job Address � City Lot Size /PM Owner's Name Vgo(t�7 (Otp Address 21,7." Al. CA1,'jytAi,AA1 WA1/Nyf 6tz, Phone d T•�"7116_r� V,� d Contractor Address 7,Xf Hzfflf License No. Phone9rb TYPE OF WI=LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 b PUMP INSTALLATION ElSYSTEM REPAIR ElJ OTHERX r01601",y bonus 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 I ❑ Industrial ❑ Open Bottom Eli Manteca Dia. of Well Excavation F' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingru� Specifications ❑ Public )KOther ❑ Delta Depth of Grout Seal Type of GroutL,��P ❑ Irrigation -I-V--Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet.) s 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 ❑ Depth Size ` s'z. Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 cerdly.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." i The applicavlmust call for al i tions. Complete drawing on reverse side. !! Q Signed Title:JFIf f0 a ��ld �5 Date: 11 l� FOR DEPARTMENT USE ONLY / Application Accepted Date !�3 � Area L4*0 65, d Pit or Grout Inspection b� Date Final Inspection bye Date Additional Comments: ❑ Stk 466-6781 PKLodi 369.3621 ❑ Manteca 923-7104 ❑ 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 OK RECEIVED BY DATE PERMIT'NO. INFO CxSff + EH 14-24[REV.i/a51 ,� ��`— 3 , �7 Sg EH 14-28 � O K7