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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'i Telephone (209) 466-6781 PERMIT EXPIRES 1 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. Job Address `' �L City Y K� Lot Size tZ 14 M Owner's Name & t h ` U - GXC. y I A)s Uq /r� L Phone 2ackd- Contractor w4/(— J Address CERN G— (A ArVr License No.37 (/0 Phone 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I*OUNDATIO.N_ -AGRICULTURE WELL OTHER WEL;�--_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom I ❑ Manteca Dia. of Well Excavation Dia. of Well Casing —R-Domestic./-Private A— CI-Gravel Pack —..--.,-❑Tracy—— .—Type of-Casing - - Specifications _ - (1 Public k ❑ Other ❑ Delta Depth of Grout Sea] Type of Grout S i I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. Y^S tate rk D D_ Well Destruction lGY Well Diameter Sealing Material Itop 501 S "r Depth, ti Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l 1 DESTRUCTION I 1 Mo septic system permitted if public sewer is I available within 200 teet.i 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 ❑ TypeIMfg " '" " "" "' ' "' Capacity No: Compartments I PKG. TREATMENT PLT. ❑ It Method of Disposal 1�1 Distance to nearest: Well Foundation Property Line LEACHING EINE, ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well {Foundation Property Line E SEEPAGE PITS l I Depth Size Number SUMPS CI 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: "ktmo.Q 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 Californ' . The applicant s ca or eq r ins ctio s. Complete drawing on re1�°(�e side./ I —�-+ Signed X Title: 11 1 r a/��V rL r` Date: n. FOR 610ARTMENT U E,ONLY-,' Application Accepted by Date` Area Pit or Grout Inspection.by Data Final Inspection b Data r r Additional Comments: c t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental_Health_P_ermit/Services.1601_E..Hazelton-Ave.,—P.O. Box-2009,-Silk., CA 95201 FEE t t INFO AMOUNT.DUE- AMOUf REMITT O CASH- "RECEIVED BY -DATE ��PERMIT-NO. + EH 1324 IREV.t i H s1 uxy EH 14-26