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APPLICATION FOR PERMIT l ' A 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 i 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. J Job Address _ It CIA a/ /TL n f N ! ��- City f r _ Lot Size PM Owner's Name a I,t! k LEGAL IS Address Ir N";7 0'5—Al- aG k1bItI _Z____ Phone /3/ J 's—J �^-J 'R n �^ �4 i q,,5,gk q -3131 1,39 Contractor JOR9 3 In F/IEC_ Address 'Rt( N J IL-c G� �� License No.7 Z Phone3122 - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 04 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other n Delta Depth of Grout Seal Type of Grout _ _ X Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by f �- H.P. n5_ r�/I �iS Tri Repair Work Done ❑ Type of Pump ljk State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r=R 1A 1—1 l f. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 r Property Line pA-YMENT — aECFAVEo SEEPAGE PITS I I Depth Size Number L 102 SUMPS LI Distance to nearest: Well Foundation - - -- Property Line I '� Ww DISPOSAL PONDS ❑ JOAQUIN COUNTY I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo*wNME p ��%04VA , and rules and regulations of the San Joaquin Local Health Di1trict. NVIRO1� Home owner or licensed agent's signature certifies the following: "1 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 all,required inspections. Complete drawing on reverse side. /� Q /.Q _10-Q Signed X Title: Date: 41 FOR DEPARTMENT USE ONLY � ` Application Accepted by �>.i�nN�i Date`t/l_VS�Z Area Pit or Grout Inspection by Date Final Inspection by N I Date 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 AMOUNT DUE AMOUNT REMITTED CK R CEIVED BY D E PERMIT NO. INFO +.EH114-Za 3-24(REV.i i x s) EH 4-e;-o o