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APPLICATION FOR PERMIT '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 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 ASO b a Of FAN) IS LA Vb li City Lot Size PM Owner's Name t Address �•v W �y Phone v Contractor w LL Address O r4 F_• ✓ko csii N0. 5 hone V TYPE OF WELL/PUMP: NEW W ELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ ATION 1 PUMP INSTALLSYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE S� FOUNDATION AGRICULTURE WELL OT R W L PITS/SUMPS _ s INTENDED USE TYPE OF WELL PROBLEM AREA C TRU TION SP CIFICATI N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exction - Dia. of Well Casing K\ Domestic/Private ❑ Gravel Pack ❑ Tracy' T VOLV`\ y ype of Casing Specifications �� I"1 Public Other Ll Delta Depth of Grout Seal Type of Grout I Irrigation __Approx. Depth t'I�Eastern Surfc Seal Installed by C.`��TWew_ _ Repair Work Done ❑ Type of Pump �a w H.P. State Work Done J-loo-AA►1. Well Destruction 0 Well Diameter _ Sealing Material (top 50') �\ Depth_ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 11\ available within 200 feet.) �4. 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 Q� 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 ❑ 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, an rules and reg tions of the San Joaquin Local Health District. Home owner or 'censed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any rs n in such ner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies tit olio ing:"'I,c rtit th tin the ormanc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws a ornia." The appli s c for all r ire i i s. C plate drawing re a sid6 Signed X Title: VV Date: FOR DEPARTMENT USE ONLY Application Accepted'by i• Date Area Pito Grout Inspection by,_4eDate W Final Inspection by cs �" Date Additional Comments. 51�'dr �^W .. L��i%J �/6G�E��c�®�f�S/✓ ood�l�c i7/ �,rw�e �/� ❑ Stk 466-6781 ❑ Lodi 621 ❑ Man eca 823-7 04 racy 835 6385 fe�E��idL Auf¢'a�� %FG�Z � 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 INFO RECEIVED BY DATE PERMIT'NO. // CA +.EH 114-28 3-24(REV.18 5)EH C 1� Ch� l ////