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iAPPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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 VS I City L 0 I Lot Size PM Owner's Name Tv Le I, CO N/S Tr • Addressi Phone J.3 q — 1-411 IC Contractor C I � N e I d er Address 2- -Jr ` M f � 4 0 N License No. 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ry ETD n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing f°V C- Specifications ❑ Public 19 ❑ Delta Depth of Grout Seal 3 0 cr- Type of Grout C -e eAd CD Irrigation �Otth�er & Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ 419m Well Diameter Sealing Material (top 50') f ail IV Depth Filler Material (Below 50') TYPE OF SEPTI WORK: NEW INSTALLATION ❑ REPAIR/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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county orcinances,•state laws, and rules and regulations of the San Joaquin Lobel 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 applican must call for all ;ped plete drawing on reverse side. SigTitle: 661 A 9)'41"'0 1 fyl Date: Q V FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection Additional Area Inspection by Date ❑ Stk 400-bAn - U Lodi 309-3821 ❑ Manteca 873-7104 ❑ Tracy 636,M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 EH 1XU JAW. Vey) EH 1426 FEE NFO AMOUNT DUE AMOUNT REMITTED 0 N RECEIVED 9Y DATE PERMIT NO. X13 0o LE s anti W rW U 1