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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 S'YY( N ERMIT EXPIRES 1 YEAR FROM DATE ISSUEDZ(f 70 2�© (Complete in Triplicate) o Application is hereby made to the San Jo urn ocal 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., Oq/`02*—-6'/0 �3/�-/3 p e� c /, Job Address Ltl. 9� �Q�t'i s0r1 S'f'Fr1'tt.Val Qf m f�i 7R��City �-+► Lot Size ��aG�S PM Owner's Name ` ✓ Pif Address V40C �IT+zG Rfi,4 Phone ContractorS le &-Address of SE. I r e.S License No.,S/ G.+� Phone S" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X �p reaf realA7l?w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1��,�I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Ddw INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fr [IIndustrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing {4- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Ll Other ❑ Delta Depth of Grout Seal Ty a of Grout SCA _ I I Irrigation —_.Approx. Depth I I Eastern Surface Seal Installed by Z12.1 , _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. 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 I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 DiMrict. 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 Califor The applicant m t al or all required i s mplete drawing on rey4se side. Signed X �' Title: Date: F R D PARTMENT USE ONLY Application Accepted by Date Sr / Area / Pit or Grout Inspection by Date Final Inspection by Date,-Z/17A 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 Ila AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.I/H5)-a[ �, lt�- Iqq_ l EH 14-28 s� l