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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) r T' 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: _ _ /�-d L� Q/—' Job Address d 7 1.�Ly a city Lot Size PM Owner's'Name �/ �`U L RO V/R�et Address ��t// � i' 't phone Contractor _IWJ 1 RE Address License No. Phone TYPE OF WEL0P_UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW[R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .INTENDED USE TYPE OFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 . ❑ Delta Depth of Grout Seal Type of Grout - J`t ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ _ Well Destruction L❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is /�� r "ova"able wit n fee Installation will serve: Residence— Commercial_" Othe Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: W er 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 v .. / FILTER'BED ❑ Distance to nearest: Well — Foundation Property Line .SEEPAGE PITS ❑ Depth Size Numberd� SUMPS ❑ Distance to.nearest: -• Well Foundation PPoperty Line DISPOSAL PONDS ❑ c_y Ihereby certify that ['have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and y rules and regulations of the San Joaquin Local Health District. -. Home owner or licensed agent's signature certifies the followirig:�•"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 II f" a `'red ins tions. Complete drawing on reverse side. Signed XTitle: Date: 1. ;.; FOR DEPARTMENT USE ONLY Application Accepted b'q " " m Date Area _ _r 2 5- p Pit or Grout Insection by p�9 Da a Final Inspection b Date Additional Comments:` -w ❑ Stk 466-6781 ❑ Lodi 369-3621,.P4,° X Manteca 823-7104 ❑ Tracy 835 5 Applicant - Return all copies to: Environmental_ a _th Permit/Services 1601 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201 T FEE -AMOUNT DUE AMOUNT REMITTED C w RECEIVED BY" DATE PERMIT NO. INFO `+ EH 13-24(REV.i i e sl EH 14.28