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APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRI 1601 E. HAZELTON 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. {{ �jj Job Address Ya4 6,%,5, r q S- C11�e 1Y0 I{{�ep— City Gt 1 Lot Size PM Owner's Name V_a_LlO 0.11 elo- Address LLI C 41041N C�iCT}zt t� �#a,7/V Phone Contractor O>/ Q`tt Address S� NJ�d ff!t/ry;M& License No. Phone&/S �? r 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavati n — Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingyC- ,. Specifications Peit��Q/!/ h`��l Ot#�erf ❑ Delta Depth of:Grou`t deal �'y Type of Grout ❑ Irrigation 14 Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 1 State Work Done (��l Well Destruction 0. Well Diameter Sealing Material (top 5b') ' Depth Filler Material (Below 501 - - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ;DESTRUCTION ❑ (No septid system permitted if public sewer is available within 200 feet.) i Installation will serve:t Residence_ Commercial_ Other Number of living units:-""" --Number of bedroortTs Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypeJMfgCapacity *- No Compartments,.' S 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 ❑ 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: "1 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 lr`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 call for all required ins 'ons. Complete drawing on reverse slide. Signed Title: t3�'/G�,(/1 Date: 3 z `. FOR DEPARTMENT USE ONLY /7`�Application Accepted by � Date cam/ / Are Pit or Grout Inspection by _ Date Final Inspectionby -- X_:,O, "" Additional Comments: IV `��• 40 w ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 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 RECEIVED BY DATE PERMITNO. a. O ' 1a ♦ EH 1324(REV.1185) y�/ {Q.j�, O� ��,� /y C EH 1426 "`��'iii u+uu" 1 /�S'_j 2 Js-Zq3 1