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APPLICATION FOR PERMIT _. P 4 Td^4 SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, .CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM,DATE 'ISSUED'' (Complete in Triplicate) Y' 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 Ryles and Regulations of the San Joaquin Local"Health District. 1� s } "40 �� - r Job Address�7 I/ . r �? S "/�,g7tr r *5 kl , GB'"#A Y i City ,ZLG-[ Lot Size-lsA PM s-t �i'J;. i f'i .i.f' r• - t , _ 5 -rtJrf �h- '' Z'ti_ •- .Owner's Name. 0 OJ(6 Address = - "= =Phone Contractor �" �[-G-7Z AddressO �lQ. License No. � ��Phone TYPE OF WELL/PUMP: NEW WELL"O WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 T_ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack i❑ Tracy f 'Type of Casing Specifications y ❑ Public ❑ Other - ❑ Delta f I Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump `�, I H.P. State Work Done j Well Destruction \ ❑ Well Diameter 1r! Sealing Mateiial (top 501 Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION [],(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other ' t Number of living units:--I— Number of bedrooms j � Character of soil to a depth of 3 feet: ? 13 Water table depth SEPTIC TANK ❑ Type/Mfg —_ � i Capacity -` No. Compartments 1 't PKG. TREATMENT PLT. 1-1f i j i s Method of Disposal Distance to nearest`..,...._,.WellFoundation��'Property Line LEACHING LINE No. & length of-lines Total length/size FILTER BED ❑ Distance to nearest: Foundation >0 Properly Line __.14 SEEPAGE PITS ❑ DepthSize Num er ' SN b SUMPS ❑ Distance to nearest: Well �' Fou ridation _-----,....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 performarice'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 perform6n6e"6f theitiork for Which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I ,. The applicant must call f r all re red ins ctions. Complete•drawing on reverse side. Signed Title: �7 , Date: FOR DEPARTMENT USE ONLY tF ® " Application Accepted by Date 2'' Area Pit or Grout Inspection by Date Final Inspection by Date( " Additional Comments: ❑ 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.fl. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* NFO CASH RECEIVED BY , DATE' PERMIT"NO. I + EH13-241REV.1/e51 EH 14-25—_