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EI � APPLICATION FOR PERMIT 1pirm _ i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED r (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 Counry Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distrito. Job Address ad Y.-96Al,� 1. City ' Lot Size �- PM Owner's Name Address �G�L�� Phone Contractor T ��►9 Address_,Y_t 6- 15!�Y- 7 S� License OlYn t_3 Phan, 12- 60' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl x PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR ICU LTURE'WELL OTHER WELL PITS/SUMPS � INTENDED USL TYPE O.F1WELL't PROBLEM AREA CONSTRUCTION SPECIFICATIONS ..a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of'Wei1 Excavation Dia. of Well Casing Ll Domestic/Private L1 Gravel Paick ❑ Tracy. Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout F I I Irrigation _Approx. Depth I I Eastern Surface_ Seal Installed by _ Repair Work Done ❑ Type of Pump H.P.- State Work Done _ * Well Destruction ❑ Well-biameter o- Sealing Material (top 50')_ Depth ' ''Filler—Material (Below 50') `TYPE OF SEPTIC WORK: NEW INSTALLATION-i-;1—FIEPAIR/ADDITION DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet-( Installation will se'rve'r(Residence Commercial""` "Other Number'f iving'units: Niimbero bedrooms, F rr Character of soil to a depth of 3-feetWater table depth *SEPTIC TANK E-) ",Type/Mfg Capacity -..:No_Gompartments O~ 'PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE No. & Length of lines {f( f Total length/size FILTER 9ED EIDistance{to nearest: Well _ Foundations / a� Property ine SEEPAGE PITS I 1 Depth Size _ Nunhber " SUMPS L1 Distancetonearest: Well ' Foundation a` r 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 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 f certifies the following:y'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." � 1 The-applicant must call for all required inspections. Complete drawing on rev rse-side. Signed X - Title: Date: !fL/ F R DEPARTMENT USE ONLY n r� Application Accepted by vt � n ,, _. Date i:� �r Area ~ Pit or Grout Inspection by Date Final Inspection by Date 7�' ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE � INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DAT> ('PERMIT NO. , +.EH 13-21(REV.i r»51 6 O r0� I v" `� W t 1_a�24 T rC ( g `� /r V EH t4-ZB "1