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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED © 15—3 ,1 f ,, S p (Complete in Triplicate} II 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. I� Job Address [moi �Aa+ �* Qtp, �cmi x P_Ci=S I �hi i City of Size PM Owner's Name V ��h C �,0) Address -3 f�JY+ Va lYl1� Phone, / n Contractor V4 8V 14 -bJf� '[ n Address `�f9. Licens �hon s TYPE OF WELL/PUMP: NEW ELL D WELL REPLACEMENT ❑ STRUCTION PUMP INSTALLATION D SYSTEM REPAIR ❑ ki€ 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F` Public f1 Other C-i Delta Depth of Grout Seal Type of Grout i I I Irrigation —.-Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of.-Pump— .----H-P. � State Woo Done_ I' Well Destruction Well p�/� Diameter � � Sealing Material Itop 50'1 �- Depth 1 NO Filler Material (Below 5011 TYPE OF SEPTIC;WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence_ Commercial Other - -- - ——" j Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Coinpartmentsk i ._.PKG.-TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LINE ❑ No: & Length of lines Total length/size FILTER BED— -- ❑ Distance to nearest: Well Foundation Property Line II SEEPAGE PITS I I Depth Size Number 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I` i 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 Di§trict. 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." The"applicant must II for all required in ctions. Cgmplete drawing on reverse side. m P M r Signed X A ' kt� AA A.A — Title: a° Date: OR DEPARTMENT USE ONLY Application Accepted by- Date Area Pit or Grout Inspection by DQ(__ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 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 INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH13-24{REV.I/A b) � "R'`�` ��tf9 / EH 14-29 000