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SO APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT `, 6 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 Distr- t Job Address a( � A.,/ it L�Q1.Xcet PM Zia.-I Owner's Name �D CiL,16iAddress- d� 0,01 S - UI�I-Phone i�p Contractor44e_ res ©� - (q 9:7icense No. T 62,37APhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L�- 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 F] Pu lic ❑ Other F] Delta Depth of Grout Seal Type of Grout I Irngation / Approx. DeUjJa. I I astern Surdce +Installed by Repair Work Done i•V,'/ Type of Pump �-7 LAJO H,P. 2 s State Work Don bow I's Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 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 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 ❑ Ll. 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 regulati t e Joaquin Local Health District. Home owner licensed agent's nature certifies the foil : "I certify that in the performance of the work for which this permit is issued, I shall not employ an arson in such mann as to b o subjec o w rkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies t e following:_"I certify t in th pe of th work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of California.' The app cant must c requir i plate n r R ide. Signed X Title: Date: 21 J? R DEPARTMENT USE ONLY ( 1 c� Application Accepted by �C�� r� Date �O�C>`✓, Area Pit or Grout Inspection by Date Final Inspecti 6y Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT NO. + EH t4-26 IREV.1 i H 51