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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES TYEAR 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. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 8 / 17 SA Al C-ZI/.rl X7"7—/ 4AiV A- City 4;-,7<IJ Lot Size 173_ PM Owner's Name AJ Q&EAle- AA/,T /C l( Address SAaYJ - - Phone 1V411-7Y143 Contractor FLen) Wd©7 Address 7 N. /qg:/g License No.!_3-i'L7` Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION A ICULTURE WE OTHER WFLL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A C STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EJ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications I'1 Public f Other C1 Del DSth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth l I stern urfa Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done T CIO Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION (NGseptic system permitted if public sewer is r�} vailable within 200 feet.) t/ J 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 r" 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 I i Depth Size Number SUMPS ❑ 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 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 must call for all required inspections. Complete drawing on reverse side. q Signed X wa. --- Title: 611aiL Dater OR DEPARTMENT USE ONLY Y Application Accepted by r( Date J � ArealA" Pit or Grout Inspection by Da Final Inspection by Date Additionai Comments: ❑ Stk 466-6781 ❑ Lodi 369-360 ❑ Manteca W-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EFEEO AMOUNT DUE AMOUNT R^^EnnMITTED y CASK RECEIVED BY DATE PERMITNO. +.EH13+241HEV.1/851 EH 14-26 L