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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON 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 City Lot Size Q4- X 4110 PM Owner's Name ^�`+21 Address 117 1;.#�.f.L1LC� f Phone Contract uF.6 Address ,b.` O x -7&_7 �—License No. �Z gZZ�e Phone 00 -!K1 O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �Jyl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 Seat Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seat 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 available within-200 feet.) Installation will serve: Residence Commercial—_ Other Number ofliving units:-� Number of b oms / Character of soil to a depth of 3 feet: Water table depth �S SEPTIC TANK v B"' Type/Mfg -- Capacity 1!Q®D No.-Compartments PKG. TREATMENT PLT. ❑ r M;jthvd of Disposal Distance to nearest: Well -Foundation Property ines LEACHING LINE JK No. & Length of lines ( Total length/size Q Y FILTER BED ❑ Distance to nearest: Well QQr Foundation ($r Property ine SEEPAGE PITS &K Depth t1-? Size 3�J Number SUMPS ❑ Distance to nearest: Well l SD Foundation 10• Property Line 15 DISPOSAL PONDS ❑ 1 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 fallowing: "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 ust call fo I re uired inspections. Complete drawing on reverse side. �} Signed Title: _- V l . Date: Qo FOR DEPARTMENT USE ONLY f} Application Accepted by Date �/ Area Pit or Grout Inspection by Date Final Inspection by Date Li" i) B 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 CASH CK Ot RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV-1/a 5) EH laze • a l�'�/ �40�310 S