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APPLICATION FOR PERMIT j �l jA ` �v SAN JOAQUIN LOCAL HEALTH DISTRICT (J IIS 1601 E. HAZELTON AVE., STOCKTON, CA G^' Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED �1 0 (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. 414 Job Address f City LQQ Lot Size J �� 1 Owner's Name 1 � N y Address O� APhon Contractor Address License Ko.� —Phone TYPE OF WELL/PUMP: NEW WELL ❑ Bo" WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION V iekpkVZ0 WTSYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ndustrial E3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public n Other n Delta 'Depth of Grout Seal Type of Grout I i Irrigation / Approx. Depth l I Eastern Surtace Seal installed by - Repair Work Done If Type¢f Pump �— H. State Work Done_ Well Destruction El Well diameter Sealing Material (top 501 ' Depth) Filler Material (Below 501 �1 TYPE OF SEPTIC WORK: NEW,INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic systhin m permitted if public sewer is avai . 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 1 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line I LEACHING LINE ❑ No; & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation a Property Line SEEPAGE PITS 11 Depth Size- -.-- Number SUMPS 0l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I havepreparedthis 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 l 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." — ` F The applicant f all TO spections. Complete drawing ongey- rse 1'y e. Date: I Signed X =DEPARTMENT USE-ON:�� 'z Date _7 re 0'- rea �✓ I Application Accepted by , ryi 1�r I ► `_11 ` d Pit or Grout inspection by Date .:Final inspections by Date Aditional Comments: . .. E]__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 20091 Si`k., CA 95201 FEE AMOUNT DUE AMOUNT REMIED C SH RECEIVED BY DATE PERMIT NO. TT +.EH13.241REV,I/K5f {NFO ��_� '� EH 14-26