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APPLICATION FOR PERMIT IL-101 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. i l /yam y�` 1 - q' I r1"" ' Job Address`" Gy "A 7 4 � r City 5keJdy of Size PM Owner's Name V�� I � ��L _� Address C7 > C� / \ one 10K Contractor � Contractor l04Address License No. Phone 414S:-137 TYPE OF WE L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑3 PUMP INSTALLATION ❑ SYSTEMaRREP4tR El OTHER )k601 ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES�,r Cy,--DISPOSAL FLD. PROP. LINE� u 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 Casingnr�,� Specifications �I _ M Public n Other 171 Delta Depth of Grout Seal �s 4-Type of Grout _ t I I Irrigation .Approx. Depth l 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 F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION I I (No septi system permitted if public sewer is avail within 200 feet.) Installation 'I serve: Residence_ Commercial_ Other Number of living u Number of bedrooms Character of soil to a depth of Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ElMethod of Disposal Distance to n Well Fo tion Property Line LEACHING LINE ❑ o. & Length of lines I length/size FILTER BED Distance to nearest: Well Foundation operty Line SEEPA ITS I I Depth Size _ Number SUMPS Ll 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 may) rules and regulations of the San Joaquin Local Health DIltrict. 1� 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 Californi ' The applicant m t c for all required 'nspectio plate drawing on reverse side. n� Q Signed Title: �Y C. Daj � �� u C If `FDR DEPARTMENT USE ONLY Application Accepted by IF F Date — _ Area S _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk./, CA 0 &1FEE y INFO AMOUNT DUE AMOUNT REMITTED CK V CASH RE]/C�EIVED BY �DATE PERMIIT'NO. +,EH 13.24►REV.1/H 5) .J "� t ;11� X 'IP � � EH 14-26 1 v ///