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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 3Wo Telephone (209) 466-6781 vJ PERMIT EXPIRES V 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. //r�� ry/d Jobe,Address laoc) � AE---#4)yr/�/ City G Lot Size aOi? PM ` AC L k 1 i9,R ups 17600 LtJ. &wmy (a p ,29 Owner's Name Address �/' �. � �a l f 0 �I / Phone CaItractor FLF Address �µ� 45 860VrO License No. Phone TYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Q" 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 d ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia. of"Weli Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public f7 Other Cl Delta Depth of Grout Seal Type of Grout _. 11 irrigation —_Approx. Depth t I Eastern Surface Seal Installed by Repair Work. Done ❑ hype of Pump / t,P, _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.-1 REPAIR/ADDITION t I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other ' Number of living units: Number of bedrooms a 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 LI 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 j 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 mustall for all re )red inspections. Complete drawing on reverse side. r� Signed X Title: Date: O" �s1 t gam. FOR DEPARTMENT USE ONLY 1 Application Accepted by Date If2 Area 1 Pit or Grout Inspection by Date Final Inspection by Date t _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy '835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltori Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY GATE PERMIT"NO. INFO CASH L t +.EH 1321(AW.i/nsy - V / EH 14-28 � l/ C•�••�