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APPLICATION FOR PERMIT ?a SAN JOAQUIIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) JUL 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the v � �M' tion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Mp� pry,qoaquin Local Health District. �C f~i[V p fl LDzs- r�� 5v Job Address —{ -Lk Al. Q 14-L ('ar City y Lot Size PM IF Owner's Name J AAII, Address/_`1�d aC `UQi[ryl y �[yr Phone — 6 46 Contractor z3Address /rLicense No/fie 13 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION;*�F,. SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack I❑_Tracy Type of Casing Specifications FI Public C] Other Cl Delta Depth of Grout Seal Type of Grout Vk Irrigation __Approx. Oe i I Eastern Surface Seal Installed by Repair Work Done L' Type of Pump H.P. _1 .S State Work Done_ W Well Destruction ❑ ' Well Diameter Sealing Material (top 501 V� Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIRIADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is '- available within 200 feet.) Installation will serve: Residence— Commercial_ Other l Number of living units: Number of bed ams Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ° No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: EII Foundation Property Line 1 LEACHING LINE ❑ No. & Lengt lines Total Length/size FILTER BED ❑ Distance nearest: Wel! Foun�n _ Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Wel! 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 rules and regulations of the San Joaquin Local Health Di1frict. 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-Q`" tion laws of California." - . '-___. _n - _ __ -_ — _ _. .6 .-- ..- __ The applicant mu all f all required inspections. Complete drawing on r verse side. � Signed X >s: ' Date: OR DEPARTMENT USE ONLY �--� Application Accepted by Date Area Pit or Grout Inspection byDate Final inspection)by ✓'v Dated 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 INFO AMOUNT AMOUNT REMITTED CASH CK 0 RECEIVED 9Y DATE PERMIT�NO. +.EH 13-24(REV. i n sl y l.V —Ow ' �j ,,S EH 14-28 ! Q0-