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3y APPLICATION FOR PERMIT -` .en 6RIPS5 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tV r'-1 (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 District. Al AM,',a n A S GI I � Job Address 1q ,616 . __ City �� Lot Size /0 PM Owner's Name ��'��/ f Aqr---- Address 13 a Contractor & � S�n�—Address _4!i j( d 6-A41— License No. �3 I Phone 7V.6y'z22 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK IfQQ-t- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElCt Industrial <pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q?Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .Sree tSpecifications M Public n Other F1 Delta Depth of Grout Seal a/, Type of Grout I 1 Irrigation 3w—..Approx. Depth I I Eastern Surface Seal Installed by &,'ii ✓t - Repair Work Done ❑ Type of Pump H.P. r"T State Work Done_ 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 (No septic systemthin permitted if public sewer is availableInstallation 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 Diltrict. 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 shalt 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. Signed �aA/ �11 Title:{L _ Date: FOR DEPARTMENT USE ONLY Application Accepted by / Date ' i Area Date r Final Inspection by " '�'y Date Pito Grout Inspection b � Additional Comments: _ ❑ Stk 466 6781 ❑ Lodi 369 3621 ❑ Lnteca 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 RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 24IREV: /Hs) , c'S N�� WZZC EH 14-28