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APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE; TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sark-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. Job Address iyl !f City �*a_ Lot Size &Cb PM Owner's Namegk �Y d�&C)eY Address / ��, f / ,/J1i2�11.1 ` ^=- Contractor Contractor k,5 U Address License No. Phone_ 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 4 , FOUNDATION AGRICULTURE WELL t.' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1gOther ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation a --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction Y Well Diameter �� Sealing Material {top 501 Depth ? Filter Material Welow 501 , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU ION ❑ (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 ❑ Type/Mfg Capacity Nor. 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 Number 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:g g g: "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 M#4st call for all require specti ns. omplete drawing on reverse side. Signed Title: Data: ' Ile �r FOR DEPARTMENT USE ONLY Q Application Accepted by Date � y' �� Area 042 E Pit or Grout Inspection `` Date Final inspection by Date Additional Comments: DOJO 447Z„ ❑ Stk 466-6781 4❑ Lodi 369 3621 ❑ Manteca 7104 ❑ Tracy 56385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 00 FEE INFO AMOUNT DUE AMOUNT REMITTED MCSH RECEIVED BY DATE PERMIT NO. + EH1 `3-24 Ir1EV.1 i a 5) EH 14-28