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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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. Q in Job Address 16 14 9a^- City Lot Size PM M"u��m�.�- If-4v6 Owner's Name Address Phone -,477- 99t_�l Contractor MA024YA&I 5 �Address /Cl7e5p 1=�0 icense No. OJ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca r Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy: Type of Casing Specifications M Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation __Approx. Depth s��tt I?gEastern F LI Surface Seal Installed by �j1- _ Repair Work Done Type of Pump LC� 1 H.P. I State Work Done_IQAE,0AeF 4/a, Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth [Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.I REPAIR/ADDITION I I DESTRUCTION I i iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms1 . O Character of soil to a depth of 3 feed 3 Water table depth SEPTIC TANK ❑ TypelMfg f Capacity No. Compartments f PKG. TREATMENT PLT. ❑ "1Method of Disposal ./ Distance to nearest: Well n FoundatibnProperty Line LEACHING LINE ❑ No. & Length of lines r ✓ 1 ti Total length/size �. FILTER BED ❑ Distance to nearest: Well 1i Foundati n .ems `1'—,,Property "-Property Line SEEPAGE PITS I i Depth Size + - Number SUMPS ❑ Distance oto nearest: WellFoundation Property Line 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 laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 fok which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The app^lica_nt I I require ions�,C,omMplta drawing on reverse side. r Signed X. 7 !%C 6 //,/!G !/// .� Tifl Date:' X09111 Jp/ F Ai1':MENT USE-QNLY Application Accepted by Date �+ Area I �.... Pit or Grout Inspection by Date Final Inspection by �?1 Date�.__... Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health"�Permlt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEFi INFO AMOUNT DUE AMOUNT REMITTED CA H CK RECEIVED BY DATE PERMIT'NO. �qao� - a r.EH 13-24-REV.i/�51 t EH t4-2e