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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA _ U � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tozw „ I. (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. Job Address �. � -I�O�L .._- City bGKTOb of Size 6bK1-5;0 PM i �v Owrier's Name �'--�iu'AD W L-V tpr� Address Phone /q R Contractor rr S r Address bei N r 0A70A1 License o. jz 6 _Phone " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ . SYSTEM RE ❑ OTHER ❑ DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES _ _ _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRIG E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P ) ❑ Tracy Type of Casing Specifications ❑ Public ❑ r ",LJ Delta Depth of Grout Seal Type of Grout [I Irrigation —Approx. Depth , EJ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump M.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth .Filler Material (Below 50') TYPE OF SEPTIC.WORK: NEW INSTALLATION EJREPAIR/ADDITION ❑ DESTRUCTION {No septic system permitted if public sewer is �- ' available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms 01 Character of soil to a depth of 3 feet: Water.table depth I SEPTIC TANK X Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal e Distance to nearest: Well Foundation Property Line A d w f LEACHING LINE ❑ No. & Length of lines # I Total length/size ! E; F - FILTER BED LJ to nearest: Well Foundation_ i Property Line a - SEEPAGE PITS X Depth Sire Number SUMPS ❑ Distance to nearest: — Weil --- Foundation Property Line r DISPOSAL PONDS ❑ 1 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 muecall for al wired ins a tions. Complete drawing on re rsQsi�def� Signed Yr' Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 171 A..a k DADate' Area Pit or Grout Inspectio , �TfaDate/ Final Inspection by r ( Date Additional Comments. Q� '7 ❑ Stk 466-6781 ❑ Lodi 369-3621— Manteca 823-710-4., ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton'Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.1ie51 ��7 EH T4-26 L,r I I_1