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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT P 1601 E. HAZE T ON AVE., STOCKTON, CA RECD VE Telephone (209) 466-6781 Q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ JU 12 (Complete in Triplicate) rNV� ( 1 X90 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wy rQ riped. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RuISQ '' PLolit / fe_San Joaquin Local Health District. 1CC��ff..ff Job Address 111,S-1 9QA11 City JnAJ37Z A Lot Size PM 04 Owner's NameQkl�f•� r K��—�� Address Pt' aZDg,3� N►��y- - Phone Contractor L w�. _ Address License No._�� –Z 4 FPhone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER F_ ^t�^�' r vim– -C'L L DISTANCE TO NEAREST: SEPTIC TANK .5D SEWER LINES A)/,e DISPOSAL FLD.A1�q PROP. LINE 412 z FOUNDATION _&Q AGRICULTURE WELL � — OTHER WELL. PITS/SUMPS.V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation R Dia. of Well Casing e of Casing '�r ✓� Specifications ?r " E--C omestic rivat Q Gravel Pack ❑ Tracy TYp 9 r _ LA FI Public Other 171 Delta Depth of Grout Seal 4i rCK10E Ty 5 Type of Grout A Y I I Irrigation o25_"Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I ) (No septi system ithin m permitted if public sewer is availabInstallation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK Ll Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. L] Distance to nearest: Well Foundation Property Line LEACHING LINE 11 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _— Property Line SEEPAGE PITS 1 I Depth _ Size - Number SUMPS Ll 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: "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: "1,6ertify 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 Y The applicant m all for required ins ions. Complete drawing on reverse side. Date: j Signed X tle: G FOR DEPARTMENT USE ONLY f. Date Area Applicatio ccepted by / Pit;� Grout spection by � _ Date},–Z D Final Inspection by Date A ditionat Comments: [- 466-6781 ❑ Lodi 369-3621 ❑ Manteca 704 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Sces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO EH 13-24 IREV.I,X 5) �p EH 14-26