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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (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 ]:3.1 Y o 76k1A C �, A �j / Cityt f Lat Size PM Owner's Name u�!LC >//�+ A { �� s7� M r� .�� /'Cly_ Address Phone d� t,-,�� Contractor e�+�Y� (��c1�S Address 151 License NoJ 77 3 7� 7/r- - Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK _l��a SEWER.LINES DISPOSAL FLD, PROP. LINEA FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom I .❑ Manteca Dia. of Well Excavation /� Dia..of,Well.Casing Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing 1% Specifications \ M l Public ❑ Other 1-1 Delta depth of Grout Seal .�` Q Type of Grout T_. I I irrigation `1.Gd.-Approx. Depth l I Eastern Surface Seal Installed by C 21,-� ACJW Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well DiameterSealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 13 DESTRUCTION i I (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 Capacity No. 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 I 1 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, stale 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: /'0.-� 3 - __. Date: FOR DEPARTMENT USE ONLY Application Accepted by ��` Date �` Area Pit or Grout Inspection by Dater II{�}tal Inspection by Date Q : ku( 4 0 St oval Comments , `� 2 Lt j � tier 0,/" "� St466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 + Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - &Leq,0 ,. um FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT NO. �y +.Eli 13-2 (REV. /n 51 / I a,Ic/ Q� X,7 �9 EH 14-28 ! L 7 0