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8 ti.•/ APPLICATION FOR PERMIT SAN JOAOUIN-LOCAL HEALTH DISTRICT 1.e.- ALV lb4 PT 4ur 1601 E. HAZEL T ON AVE., STOCKTON, CA k-) r,-+i 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. [Jobddress City Lot Size PMr's Name '� Address , r � FvrvS�o�r Phone 6-0vtactor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 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 OF WELL PROBLEM AREA t CONSTRUCTI0'N SPECIFICATIONS 9 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private I] Gravel Pack ❑ Tracy i' Type of Casing Specifications ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Grout " ❑ Irrigation ___,Aliprox. Depth ❑ Eastern # Surface.Seal Installed by k3 Repair Work Dane ❑ Type of PumpH.P. State Work Done_ Well Destruction ❑ Well Diameter w Sealing Material (top 501 1 Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—3 Commercial— Other" r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: = Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. O w 7 Method of Disposal Distance to nearest: Well Foundation Property Line i 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 j rules and regulations of the San Joaquin Local Health District. it 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 m_ust call for all a fired inspections. Complete drawing on reverse side. Signed X Title: �!/r'/r/ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b Date T 7 Additional Comments: LJ Stk 466-6781 ❑ Lodi 369-3621 L1Manteca .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 ; y FEE AMOUNT DUE AMOUNT REMITTED C H RECEIVED'BY DATE PERMIT NO. INFO -+ EH 13-24(REV.')/"5) �L7 EH 14-28