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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1641 E. HAZELTON AVE.,,STOCKTON, CA Telephone (209) 466-6781 Y k / PERMIT EXPIRES 1.'YEAR FROM DATE ISSUED (Complete in Triplicate), #a 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. K Job Address YZ_ city$1tn_G/fr'{n1 Lot Size PM Owner's Name r Address J – ,µ _Phone Contractor IM55 6d,62-,E _. Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ ,f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca . Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout 4 ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done sf Well Destruction ❑ Well Diameter Sealing Material atop 501 - Depth Filler Material (Below 501 Il TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO �1'. �°"'^' N INa septic system permitted if public sewer is 14 � � �"" _ � � available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: i Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal � : Distance to nearest: Well Foundation Property Line I 1 l LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest:. Well Foundation Property Line SEEPAGE PITS ❑ Depth ' Size Number i SUMPS ❑ . Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 follovn in :,"I certify that in the performance of the work for w 9 Y Pe hick this permit is issued, E shall not employ an person in such manner as to become subject t Y P I o workman's compensation laws of.California." Contractor's hiring or sub-contracting signature nature 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. Signed ! 9 Title: bate: _ v r FO EPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Gate' r Additional Comments: (10 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ fracy 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 CK RECEIVED BY `DATE PERMIT'NO. + EH113-241REV EH .1/H 5) 428 C,:L7