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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, I Job Address 16 yo a I L7 ` T7V�lls,1��..�__ _ City L— I Lot Size 4C PM Owner's Name 5Al�u� Address U rn Phonea6 d12X T Contractor Address OD��f License No. �w V Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 71 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing 1_1 Domestic/Private ❑ Gravel Pack { 1 Tracy Type of Casing Specifications f'1 Public f-1 Other i 1 Delta Depth of Grout Seal Type of Grout ___.._ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia! (top 501 Depth Filter Material (Below. ') _ TYPE OF SEPTIC WORK: NEW INSTALLATION i I f1EPAiR/A0DITIO DESTRUCTION € 1 (No septic system permitted if public sewer is �// available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: A_ Number A bed`ro10 s 2 __ r Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK No� Type/Mfg OQ��_ �� _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well_.� V Foundation iii 5 Property Line A LEACHING LINEI�No. & Length of lines �n T tal length/size �� FILTER SED ❑ Distance to nearest: Well_ Foundation Property Line � e r f w � SEEPAGE PITS I 1 ❑❑ pth Number SUMPS I - Distance to nearest: Well--� 0 Foundation ► I�/ 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, an rules and regulations of the San Joaquin Local Health District l _ 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 must call for a req ired inspections. Complete drawing on reverse side. Signed X Title: IV Date: AF FOR DEPARTMENT USE ONLY I , Applicati Accepted by ' - �. Hate Area Pil '9 _ Z7 or rou�ltispe tron by �I "f E',�a { ' ,` ..�� (nal Inspection by Additional Comments: ❑ Stk 466-6781 1] Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 K RECEIVED BY DATE PERMIT Pi O. INFO CASH n 4 +.EH 13-24(REV. i w 53 / �>< T/t 1 _ EH 14-26 1. ( 1. r I VVV l `�j._ /J