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APPLICATION FOR PERMIT ..,) SAN JOAQUIN LOCAL HEALTH DISTRICT � } 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR.FROM DATE ISSUED 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 V f N E, _ x City Lot Size � /_50 PM Owner's Name _° - Uh un Address Phone 1 r Contractor)AIRL_+_0A44__—_(:MAC Address SD W License No. Phone1 TYPE OF WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia" of Well Casing ❑ Domestic/Private 1 `❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation «S___4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ! 1� {NCyetrptic system permitted if public sewer is aavailable within 200 feet.) installation will serve: Residence LA `"Commercial_ Other 1{ 4 Number of living units: Number-of bedrooms t Character of soil to a depth of 3 feet:,?_/ Water table depth SEPTIC TANK i XType/Mfg C Capacity I No. Compartments PKG. TbREATMENT PLT. OA r y ; '� Method of Disposal .� ' } _ Distance to nearest: Well Fo dation ` Property Line \) ,� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation +Property Line 1 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: 4-Well -- Foundation------ T Property Line DISPOSAL PONDS i ❑ 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 ert'rfies the following: rtify that in the performance of the work for,which this permit is issued, I shall employ persons subject to workman's compensa- tion f California.:' The applic t st call for all eq u" dins cions. om to drawing on r verse side. v Signe Date: 4�,,-FOR DEPARTMENT USE ONLY Application Accepted by �7 Date �{` Area Oil Pii or Grriut Inspection Date �' Final Inspection by Date�"la—�� Additional Comments: a�_�� _ ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ha'zelton Ave_, P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO" INFO EH1 (REV EH 14284-0 .1/n 51 � c;,10c;,103 cam- 'V-7/.A7 17 1&7-�I -