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APPLICATION FOR PERMIT we/l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {2091 466-6781 PERMIT EXPIRES TYEAR 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 ZI ,-_ nr !/,-- City Lot Size PM Owner's Name Yl- VIA S?_ d')l-�.�/C Address f 43 &4 A144 Vw 7- Phone lP Contractor FI�-d,Z 1c)6LcV7_') Address 7 Al. ADE LZ7,r r W License No.4Zj Z7( Phone 44_S`-37-71 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private j❑ Gravel Pack L1 Tracy Type of Casing Specifications 1-1 Public f1p Other n Delta Depth of Grout Seal Type of Grout _ I i Irrigation' !__._Approx. Depth f 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 Fillet Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION"I'F REPAIR/ADDITIONI`l CFESTRUCTION (Na septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms `V Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK tD ;Type/Mfg yCapacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance t arest: Well Foundation Property Line r LEACHING LINE ❑ filo. & Len_gth of lines Total length/size FILTER BED ❑ Distance,tb nearest: Well 'Foundation Property Line SEEPAGE PITS l I Depth L Size _ Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 Di3trict. 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 must call for at[ required inspections. Complete drawing on reverse side. Signed Xr �� Title: fir:r Date: FOR DEPARTMENT USE ONLY ^� Application Accepted by - — - - "'Date Area i crU Z- Pit or Grout Inspection by Date Final Inspection by Date<�L Additional Comments: l/ ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 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 INFO AMOUNT DUE AMOUNT REMITTED CA&H RECEIVED BY DATE PERMIT-NO. a.EH 3-24(FIE EH 14-28