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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,' A f (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. L. :_4u I Job Address 00qV CityU /a�fC E+ IL'ot Size PM Owner's Name;5QAer2A/l iI4 CoRboAddress �JP, fir?"TaS� Phone I ' 3;Z/0 fn)tLra'cTor �' TOR ddress`+ 1' N 1/�f G'�x ROA"" License No.ZG7IL Phone TYPE OF WELL/PUMP: NEW`WELL,❑ WELL"REPLACEMENT'❑ DESTRUCTION ❑ PUMP INSTALLATION DISTANCE p OTHER,❑-..r ... DISTANCE TO NEAREST: SEPTIC.TANK i 3_ `' SEWER LINES DISPOSAL-FLD. PROP. LINE I FOUNDATION I, s k AGRICULTURE WELL` ----OTHER LWELL PITS/SUMPS x _ INTENDED USE_ .._ _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy€ Type of Casing I Specifications ❑ Public ❑ Other ❑ Delta _ Depth of Grout Seal T ' ype of Grout' ❑ Irrigation --Approx. Depth ❑,Easterp Surface Seal Installed by Repair Work Done Type of Pump lj/ q'p• f State Work Done 1 r S Well Destruction ❑. Well Diameter Sealing Material (top 501 { Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ . REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is y l t available within 200 feet.) (✓ Installation will serve: Residence_ Commercial Other 4 A Number of living units: Number of bedrooms Character of soil to a depth W 3 feet: `Water table depth SEPTIC TANK ❑ Type/Mfg Capacity r No. Compartments PKG. TREATMENT PLT. 17Methodof Disposal i F Distance to nearest: Welf 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 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 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:'9 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.0 ust call o all quired inspections. Complete drawing fo_n�re rse side. Signed tel/ .TR/I �!I s Title: Date: FOR DEP{LRTMENT USE ONLY Application Accepted Date -3 Area �' Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: VV IV ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services f601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-241REV,i/a5Y ' EH 14-26 4 {