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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 / PERMIT EXPIRES t 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. 1 Job Address;,GID 4--Zf4 /h AIE Lame ZF&V. city A o2p3� Lot Size ��PM l -r ,Qwner's Name Tyy ,[r "�y��./�� Address e_441`T/rA) UR1,V Phone �� ?Z5.� Phone Contractor ' r Adtlress �n- � /✓t%C?A License Nojj, TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ., PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other fl Delta Depth of Grout Seal Type of Grout_ I I Irrigation -.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material(Below 501 �. TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.{ ` -IrivallaiioW VAII'9e1ve: Residence JG commercial_ Other Vl%►- Number of living units: P, Number of bedro ems Character of soil to a depth Lof 3 feet:. Capacity Water table depth SEPTIC TANK s]"Type/Mfg z No. Compartments /1 PKG.TREATMENT PLT.❑ ��y.�/� Method of Disposal T Distance to nearest: Well Foundation L� Property Line yQ LEACHING LINE No. & Length of lines . "'-et) PT Total length/size FILTER BED ❑ :Distance to nearest: Well Foundation 998l'— Property Line SEEPAGE PITS I 1 Depth T Size Number 5�! rr SUMPS Tx Distance w nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stale laws, and t rules and regulations of the San Joaquin Local Health DiBtrict. r Home owner or licensed agent's signature cdrtiftes 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."Contractors hiring or sub-contracting signature • ` ',Nrkes the following:"1 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 Calilonlld" The applicant must telt for requir� insrun. Complete drawing on�ryyside� p Signed / 7 Title: t Date: t FO PART T USE ONLY f�ist I Application Accepted hY Date Pit or Grout Inspection by Date , Final inspection by Date t Additional Comments: ❑ Stk 46&-6781 ❑ Lodi 365-3621 . ❑ Manteca' SM-7104 ❑ Tracy 835-63M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazaiton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DA/([TTE�G{/� PEAMR'NO. . Eh13-24iREV.Va51 I 1 t 'l�Y •V o a97 EN K25