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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. ardU� �G1/GIIL # Job Address 0)r112r City.S'E'o��'DIN Lot Size PM /� f p •Liwl nui` Creek 4596 Owner's Name 11n1I?� l/1 Address.Z�7 I t/. 11 T. ��V V. Phone ftS–7 Contractors .f Ie11A C]fTj p"dress 15 E, Jt %o License No.416Z-52- ..Phone J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 2r Mbvlt�bt`� e l � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rte, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI_Oy,S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �� Dia. of Well Casing C G Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PV6 Specifications ❑ Public ❑��„?Per 171 Delta Depth of Grout Seal t Type of,Grout ❑ Irrigation IQL1 Approx. Depth ❑ Eastern Surface Seal Installed byv` Repair Work Done ❑ Type of Pump H.P. ,,_ yState Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 /1e1;e,� l p &4m1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo 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 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 ❑ 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 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 applicant mu all for Truired tions. Complete drawing on reverse side.zSigned X Title: Date: ZRP JVIENT USE ONLY Application Accepted by Date a 1-7— Pit or Grout Ins b Date Final Inspection by Date Additional Comm s: Z– –� ❑ Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO F CASH rte,, + EH 13-24(REV.1/8 5; 3st/v 3e� �C7 13 � 3i --z$-Pip �(��?►ZR. EH 14-28 1