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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 2 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 w OBJ a4,� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED wv (Complete in Triplicate) C43 . / 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 Z#Al Al, ADSL 46E2.7— A1/E City SMAC ) Lot Size oW A I&V PM Owner's Name 20&ERT C.LA 21L Address TACE Phone Contractor FLe S/U eK_[t/®wy Address License No.!,4Y13-7L Phone .''3?7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR ULTURE WE OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Typ of Casing Specifications F] Public ❑ Other ❑ Delt Depth Grout Seal Type of Grout--,---' I I Irrigation ___Approx. Depth I I stern Surface Se• nstalled by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: —]— Number of bedrooms 7i C� 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 ation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tone Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ D' nce tonearest: 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 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 must call for all required inspections. mplete drawing on reverse side. Signed X d-a J 15 Title: Date: DEPARTMENT USE ONLY l Application Accepted by CAI, - �� a. tie+ -� Date ^ � Area Z Pit or Grout Inspection by Date Final Inspection by _5 6�'' Date 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE �yPERMITNO. ; EH142e(REV.tix5) - vf�� l ��11_ ,Q '"�l'� —