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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Aq' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED iComplete 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.�J /� Job Address �! T�VZw_v_�1� City Lot Size PM Owner's Name b• -Pe ewB'D Address AAl 446 Phone i H } Contractor .F��i� __ Address or l� i✓Iw License No!9?_1:Q5A2 Phone vY r ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ., PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (DISTANCE TO NEAREST: SEPTIC�ANK� SEWER LINES DISPOSAL FLD." PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ri Public ❑ Other i- Delta Depth of Grout Seal Type of Grout I Irrigation —..Approx. Depth I i Eastern Surface Seal Installed by ~� Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION)( REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer.is p _ available within 200 feet-) Ir Installation will serve: Residence Com a W=1 Other_-___.,.J Number of living units: �_ Number of bedrooms 13...- Character of soil to a depth of 3 feet: ba Water table depth r SEPTIC TANK ❑ Type/Mfg �,+� �.i Capacity od2eo No. Compartments t PKG. TREATMENT PLT. ❑ F� Method of Disposal Distance to nearest: Well Foundation�� ..-.--..-.-. Property Line R LEACHING LINE No. & Length of lines Total length/size �FILTER BED. ❑ Distance to nearest: Well /Dpr� r " t 'Foundation%Oi Property Line SEEPAGE PITS 71 Depth. Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ ..► I _... k I hereby certify that I have prepared this applicat bn and-ifiat t,0 work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Fleafth .District: ML A 4' k(dome 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�bjeotto workman's compensation laws of California." Contractor's hiring or sub=contracting signature i I 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:: r. 1•`." 3 , #The applicant must call f9pall re fired ins ctio s Complete drawing on reverse side. e 6 1 r r �� Signed X a '� Title: `�.r+c,�d.L� Date: 19 FOR DEPARTMENT'USE ONLY I Application Accepted by �. Date 10Area 2-6 I Pit or Grout inspection by Date Final Inspection`by1 Additional Comments: y s � ❑ Stk 466-6781 f ❑ Lodi 369-3621 O'XNanteca'-823-7104 --k—•p,Tracy 835-6385 4Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEECK w INFO AMOUNT DUE '. AMOUNT REMITTED' ,'C SH� - RECEIVED-SY, DATE -�r- PEitMII NO. +.EH 13.24(REV.5/x sl �� ^� EH 14-26 w�7D G --".K-•_»W-,...�- •.r.w-- /C7"-�e7��'G `47';P r 1