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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA W Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ItDistrict fora permit to construct and/or install the work herei`n"Vsc i is a ca n i'44- made Application is hereby made to the San Joaquin Local Health p pP 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. LIE Job Address � �a�' V City OGJt Lot Size PM Owner's Name '�1 -4� L Y Address / q S_ 'r`�h►R 0 6 /r k/ahone 416 Contractor_S t��f Address License No. Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTA NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL P EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation __Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 °u( TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is vailable 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 ❑ Distance to nearest: Well Foundation 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, and rules and regulations of the San Joaquin Local Health District. 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 u call for all required i pection Complete drawing on reverse side. Signed X Title: ® /7 C` Date: IU ► F, -USE ONLY Application Accepted by Date01 Area / Pit or Grout Inspection by Date al Inspecti by t/`�FJ� Cha -�xil�ofeDa e 6 0 Additional Comments: T I-" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5 /n 5 peded .� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE J INFO AMOUNT DUE AMOUNT REMITTED CK V CASH RECEIVED BY DATE ((PEERRMI—r N7O. +.EH 13-24(REV.1/M3 S (� (� � .6ACC-S EH 14-26