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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT t 1601 E. HAZE i ON 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 Ryles and Regulations of the San Joaquin Local Health District. dd q Job Address .QCT 1�/'� ,rte City Lot SizeZSdX�s PM Owner's Name / �Lf Gl�� Address Ad t -2p�4.ya Phone Contractor 2u "` lire Address cense No.ec<5176�p� hone ZZ.� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER /E�Q.�,/ijN- DISTANCE TO NEAREST: SEPTIC TAMC .- i SEWER LINES �r DISPOSAL FLD./Q�74- PROP. LINE14;Z_4'V- � (1. FOUNDATION AGRICULTURE WELL -=`--�- OTHER WELL Ain PITS/SUMPS X/_4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI 0 Industrial H ❑ Open Botiom ❑ Manteca Dia. of Well Excavation �� Dia. ell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �` Specifications ❑ Public ❑1,O��,th.er ��'� ZDelta Depth of Grout Seal Type of G out Irrigation �ApproJ Depth ❑ Eastern Surface Seal Installed by -� —� Repair Work Done El Type of Purr I HP. State Work Done 4 Well Destruction ❑ Well Diameter �� Sealing Material (top SO') U► 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.) Instaliatien 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 I LEACHING LINE ❑ No. & Length of lines Total length/size FiLTER BED F ❑ Distance to nearest: Well Foundation Property Line �f SEEPAGE PITS ❑ Depth Size Number SUMPS El 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 Joa uin county ordinances, state laws, and r1 rules and regulations of the San Joaquin,Local Health District. q ty 4' 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." f� The applicant must call for all required inspections. Complete drawing on reverse side. Signed X /f � - . � G� Title: _ �'� � ••-" ,�,-, Data: _ FOR DEPARTMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection byt4 Date'; Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C1Manteca 823-7104 ❑ Tracy 635x6385 Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE I AMOUNT REMITTED CK# INFO 111rrr CASH RECEIVED BY Jj2DAETEPERMITNO. EH 13-24IREV.�ie5l 3 V GEH 3426