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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 District. Job Address �s��sazr S/ City /zJ�LI� Lot Size PM Owner's Name &DZEi.) (.lJ,C3U.�ry i/ Address �� Qlyrw Q 5"r- Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 1V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout VQ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 0 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (134low 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Cor,hmercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg ICapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length oflines Total length7size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this applic tion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Locall Health District. Home owner or licensed agent's ature cern ies t following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in manner w o become lect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the folio g:"I certify that i the pert nce of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of lifornia." The appli nt must call for II requir d i ctipns. Complete drawing on reverse side. Signed Title: L741(V`i91-e— Date: cw'lidt4�1dr, A TMENT USE ONLY c ,C Application Accepted by �j Qg,,— +6 Z A�^c`)L,oaIN" Date J d"- Area o �.1 U Pit or Grout Inspection by Date Final Inspection by�C.& S&, '- Date a.U� Additional Comments: Q.� _' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M 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 RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV.1/e 5) ` S EH 14-28 +J 7