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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 Jo 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 L1 1 A V 2 City L.o J Lot Size ply S r Owner's Name o S 5 Address �. S- @ a r- V_Phone _ Contractor's Name �`r S L e_5` C, _ cense No. Phone I •� TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 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-6F WELL PROBLEM AREA .CONSTRUCTION SPECIF(ATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WellExcavation r� �� -. Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Type of Casing'-� Specifications s ❑ Public ❑ Other ❑ Delta Depth of Grout Seal` Type of Grout' ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed byA. RRepair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:,._NEW INSTALLATION 11-REPAIR/ADDITION E,-DESTRUCT-- ION 0.(No septic system permitted if public sewer is _ available within 200 feet.) 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 ❑Y...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 W FILTER BED ❑ Distance to nearest: Well Foundation• Property Line y SEEPAGE PITS ❑ Depth Size Number 4 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 f employ any person in such manner as to become subject to workman's compensationE 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 call for all required inspecti ns. Complete drawing on reverse side. t id Signed Title: v v—q-5 fit- �s"4 57Date: O `^133 FORD PARTMENT USE ONLY Application Accepted by Date T� ' Area Pit or Grout Inspection by Date Final Inspection by��/Date FZ7 Additional Comments: . A9 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 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 C RECEIVED BY DATE PERMIT'NO. INFO ASH /} UU q +EH 13-24(REV,10/831 C L0 Z e y V �O�/` EH 1426 (i l 7 1