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APPLICATION FOR PERMIT •. SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE., STOCKTON, CACX V_C� Y � ) Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LVV (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. L Rqq Job Address ' r '` �/ City 5 Z Lot Size e/- 8X>jli PM Owner's Name&1_':'S /0ZY eZJAA1 P4 Address l�Y S A0 Ell R1: j Phone Contractor 5 el, Address License No. Phone 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth,of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 ❑ Depth Size Number SUMPS ❑ 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 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,1 shall employ persons subIlLct to workmas compensa tion laws of California." 0tj (o%+{ The applican st call for all requ'ed in ctl,ns. Complete drawing on reverse side. J r 02 1� I v ry .40 Signed X � _iY` Title: Date: '� L FOR CSPARTMENT SE O LY /� Application Accepted by v Date.-(—?-- free LQAV� Pit or Grout Inspection by Date Final Ins0wti6n-b,` UVICA& �14�1 a Additional Comments: pPi /7� cU�T�I � ._J ❑ Stk 466-6781 ❑ Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO + EH 13-241REV.1/951 EH 1428 �v 1f e p'h`i e4 k. +t O � `1