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rALP I-Aal APPLICATION FOR PERMIT Y_CVP ,^5—P SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ��QQ Telephone (209) 466-6781 U4, 0th p_+' 2 (�C1f[.!! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby rtthde 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. 1 V V ! Job Address _ i � �.'Q ��e City �U ,K Lot Size PM ' t Sl[C(r?'M&q LS �G� owner's Name VL IIAddress L l S G�.�S r L)in Phone 4) Contractor GLV 44 S rj Address f0AVk -Mice`n`se N Phon 7g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ D FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREANSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �4ppro . apt' ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type o ump H.P. State Work Done_ Well Destruction ❑ Well mmeter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence— Commercial_ Other S 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. ❑ y I. 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 1k 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 law's, and rules and regulations of the San Joaquin Local Health District. 11 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: "l 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 must call for all required ins cl ns. Complete drawing on reverse side. Signed X Title: Dater ^ FOR DEPARTMENT USE ONLY / Application Accepted byj:;�Pa/ r Date! � 7 Area Pit or Grout Inspection by Date Final Inspection by DatAVA!k Additional Comments: - C17F ❑ Stk 466-6781 'Cl Lodi 369-3621 El Manteca 823-7104 L1 Tracy 835-6385 �� 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUJNT REMITTED CASH RECEIVED BY DATE �j-� �{P�EJRMI7/NO.