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' APPLICATION FOR PERMIT 4 v 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 incompliance 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 13 F 42&r. e City Lot Size D/ L PM I t�1 !'� Q/�1Qw. 12- - L O Phone I Owner's Name � Address a Contractor b - , I Address License No. IV,72/ Phone A? 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 VV FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other n Delta Depth of Grout Seal Type of,Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501NSIZ TYPE OF SEPTIC WORK: NEW INSTALLATION I I R9-:•AIR/ADDITION k,✓DESTRUCTION I I (No septic system permitted if public sewer is 14 available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: I Number o bedrooms Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal r� Distance to nearest: WellFo ndation Property.Line — d, LEACHING LINE I!T- No. &Length of lines Cf)� Total length/size f FILTER BED ❑ Distance to nearest: Well 101 Foundation 361 , Property Line D j SEEPAGE PITS W Depth cl1 Size 3 I — Number SUMPS L7 Distance to nearest: Well y I Foundation Property Line 6I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordahce with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. - Home owner or licensed agent's signature certifies the following: "I certify that in the perf6riMance.4bf'the watt 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."Cer*ractoes hiring or subcontracting 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 must call for all squired inspections. Complete drawing on reverse side. Aft _ ._ Signed Title: Vel Dat .a FOR DEPARTMENT USE ONLY Application Accepted by aA4Da Area y _ Pit or Grout Inspection by D =c; Final Inspection An" Date -, i-M Additional Comments: ❑ Stk 466-6781 O 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO —7A CASH g +.EH13.241REV.r/e5) Uc _ EH 14-28