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APPLICATION FOR PERMIT SAN JOAQUIN 1 6CAL HEALTH DISTRICT 1601 E. HAZEL—A ON AVE., STOCKTON, CA Telephdne (209) 466-6781 PERMIT EXPIRES 11'�YEAR FROM DATE ISSUED (Complete in Triplicate) ` ,I 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 j 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 0io J Ole-t, � L�C� - City 0—Lot Size 3AC /W PM . I� f 3E _ 5- Owner's Name !r/C'�,S IY? �t ___ Address 'p 7 Il A h cn � Phone h Contractor's Name �r`�� V A-alf) - Ar License No.11 0 oo Phone TYPE OF WELL/PUMP: i[ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION I� 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 SPECIFICATION ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private K Gravel Pack ❑ Tracy Type of Casing– �F_' Specifications �. ❑ Public ❑ Other ❑ Delta II Depth of Grout Sea! � r T pe of Grout 00 ❑ irrigation ( pprox. Depth Eastern IkSurface Seal Installed by Repair Work Done ❑ Typelof PPuriip eH.P: � F State Work Done Well Destruction ❑ Well Diameter Sealing,Material (top 501 Filler Material (Below.50')– 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 Commerclal— Otherl Number of living units: A Number of bedrooms Character of soil to a depth of 3 feet: �! ,Water table depth SEPTIC TANK ❑ Type/Mfg x Capacity ' No. Compartment_5�f PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: well l Foundation f Propertyr Line'x LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well II Foundation Property Line f f _ s SEEPAGE PITS ❑ Depth Size Ndmber ° SUMPS ❑ Distance to nearest: Well 'I Foundation ~ { _Property Liner ' 4 DISPOSAL PONDS ❑ i 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. 1 Home owner or licensed agent'srsignature 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 California." The applican all for all requ" inspe ns. C ate drawing on revs side. Signed Title Date: I I�. OR DEPARTMENT USE ONLY Application Accepted by all Nk �i. Date S-as^g Area Pit or Grout Inspection by II Date Final Inspection by % 2,AM' ate Jaa a-�S Additional Comments: - ❑ Stk 4666781 ❑ Lodi,I 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 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, .� S ^RECEIVED-BY,�—_ DATE PERMIT"NO. -- easy- T -nit- + I 13-24IREV.10183M EH 14-28