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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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.�[ Aukk) Job Address f ✓` CCity��eiro Lot Size PM Owner Name ��1 rr '�� Address Phone� Contractor Address License No. J V b 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 FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Jell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specific4tions ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of trout ❑ Irrigation ---Approx. Depth ❑ Eastern Su ace Seal Installed by T1,..NX Repair Work Done El Type of Pump _ H.P. State Work pone .isl1T Well Destruction ❑ Well Diameter Sealing Material (top 501 U1 Depth Filler Material (Below 50') Uf TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permired if public sewer is available within 200 feet.) .IY7 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of b0drooms x Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' PKG. TREATMENT PLT. ❑ Method of Disposaj Distance to nearest: WABII Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WeU—=r :Foundation Property Line _4 SEEPAGE PITS O Depth Size Number SUMPS ❑ Distance to neare&: 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. i Home ownr 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 an pe son in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th fol wing: " rtify that inKperf nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of,, ifornia.'The appli ust call or a r q re . Complete drawing on��,eversse side.. Signed X Title: 17 {ADate: ell,77— ' r FQR DEPARTMENT USE ONLY L Application Accepted by Date a Area �1p/ Pit or Grout Inspection by Date Final Inspection by ) Date ` /0 Additional Comments: f/i" ❑ 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 DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. + EH 13-24(REV.iiN51 C. EH 144-28