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APPLICATION FOR PERMIT S _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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. Lot Size ��Z �rC�" X�S� PM I Job Address City�C�Ku..- Owner's Naq fllf— Address 1026Cn 6'na r, Phone ' I w Contractor` Address License No. Phone TYPE OF WELL/PUMP:_ NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION El 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 ❑ Open Bottom ❑,Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications (] Public _- Cl Other fl-Delta_ - Depth of_Grout Seal Type of Grout _. w._.. _ ,....r......,.. �. _ _ V I ].Irrigation ---Approx. Depth I 1 Eastern - —,—,Surface;Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. "' State Work.Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50T�1 Depth Filler Material (Below 50') ~ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION AIJJ ,;DESTRUCTION (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: . Number of bedrooy�m^s }{ T 4 Character of soil to a depth of 3 feet;, _ a _ Water table depth SEPTIC TANK' ❑ "Type/Mfg 1 Capacity j No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. &_Length of lines { Total length/size FILTER BED, ❑ Distance to nearest: Well FoundationProperty Line SEEPAGE PITS_ 11 Depth Size _ Number SUMPS ❑ 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: "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 %X . ust call IIJ q dXinsctions. Complete drawing on reverse side. SignTitlei- ��.�'C �/ Date: FOR DEPARTMENT USE ONLY _ Application Accepted by .Ga�/r- DateArea Pit or Grout Inspection by Date Final.Inspection by Date Additional Comments: 1L��7/ 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104, ❑ 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 C SH RECEIVED BY DATE PERMIT"NO. 0 + EH 14-28(REV.I/n a) EH 13-24 j v Mav nO brPO"A-S 0