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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZES I ON 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 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. �ff A) C Lot Size �C PIM T °I Job Address ��y l N. �rllrc[.C2. ity �'*�� - "�`' Address Owner's Name AAl Phone ?�,. xE .. Cantracto I li Address �� u License No.�3Z9f2 z (P Phone3� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Ii PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i 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 171Open Bottom 171Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑,Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑,Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pu6p H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth er Material (Below 501 TYPE:OF SEPTIC WORK: NEW INSTALLATION ❑ 61tAIWADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence '� Commercial Other 7 Number of living units: � roo Nu'mber of dms . Character of soil to a depth of 3 feet: Water table'depth 3n /J SEPTIC TANK ❑ .Type/Mfg -- Capacity No. Compartments PKG. TREATMENT PLT. ❑ ��' Method of Disposal C Distance to nearest: Well Foundation Property Line LEACHING LINE E- Nod& Length of lines � r dotal length/size d FILTER BED ❑ Distance to nearest: Well SSU : Faundation,._*_,/( Property Line -� r' t SEEPAGE PITS ❑ Doth- Size Number, 'f SUMPS ❑ Distance to nearest: Well ( Foundation^ Property Line DISPOSAL PONDS ❑. ___�_ 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 i rules and regulations of the Sari•Joaquin Local Health District. ,, Home owner or licensed agent's signature certifies the following: "I certify that-in the_perfoPmance 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 oompensation 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." i The applicant m all for all uir d inspections. Complete drawing on reve'rsejsi�J Signed 1 x;Title: V..T, sj Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area -Z Pit or Grout Inspection by I Date Final Inspection by Date ,T�7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT''NO. INFO CASH + EH 13-24IREV.1/05) AZO .i `�' '� r •�� . EH 14-28 C