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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) 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 2, 6 s A1>r',C 646 4PT' City AA0V Lot Size 16U x 313 " PM Owner' Z. s Name /��A!/{� G�4>D/�� Address 2.0 �g rS /��6Q �' '� Phone / Z Contractor Set? 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 F1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout — I 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 (top 501 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 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 t1 ion Property Line LA LEACHING LINE ❑ No. & Lenl �/� Total length/size FILTER BED ❑ Distance t( o tion_. Property Line SEEPAGE PITS I I Depth _ `( � Number SUMPS Cl Distance tc r� ( y tion Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this i e 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." Contractors 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 r quired inspections. Complete drawing on reverse side. Signed X y 0 Title: 4COAJ Date: FOR DEPARTMENT USE ONLY Application Accepted by Datk n 2!) Fs \ Area 1 Pit or Grout Inspection by Date Final Inspection by- Date Additional Comments:\—��1. ,y it l�� t/ _Wsa fig f El Stk 466-6781 ❑ Lodi 369-3621 — ❑—AManteca 3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CCK 4 RECEIVED BY DATE (P�ER O. iTA + EH 3-24(REV.iir5lJ EH 14-28 II