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APPLICATION FOR PERMIT ✓� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 AV City R 4N ii:C Lot Size PM Owner's Name&,;tA oLoN JQAQyl1.1 Tut. b- tAddrew Wr.vV 12© Afkovy�xc Phone EZ3 Contractor Address License No. --------- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WEtL REPLACEMENT ❑ MES UCTION 15,, PUMP INSTALLATION ❑ SYSTEM REPAIR it _ . _ 10THER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \ v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY E OF—WELL PROP EM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialOQ' pen BottomanB'M teca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4r�/ Specifications ❑ Pudic El Other ❑ Delta Depth of Grout Seal Type of Grout I rrlgation ;J2o—Approx. Depth ❑ Eastern Surface-Seah Installed by Repair Work Done ❑ Type of Pump H.P. 4 D _ `State Work-done } Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ OESTRUOWION ❑ (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 Q Type/Mfg CapacityNo. 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, nd 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 no > 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 subject to workman's compensa- tion laws of California." Theapplicant st call for all required inspectionA. Complete drawing on reverse side. Signed e 0 Titl7v Date: Z 7 ��1/_► FOR DEPARTMENT USE ONLY Application Accepted by Date ^a� Area L Pit or Grout Inspection Date Final Inspection by rAJ&ae� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835400 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. + EH13-24(REV.1/a5) c � � EH 1428 J ��f