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APPLICATION FOR PERMIT �{ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. yy��//�� Job Address,`ozao� � — Ci Lot Size PM Owner' Na Address466 A2 &J:MM Phone,: 7 Con AddresAg �l0 XmIEAIFr� License N Phone/! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR`❑ '�_" OTHER I]DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES' a DISPOSAL FLD.( # PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O dustrial ❑ Open Bottom El Manteca Dia.'of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications y r 1 ElPublic ElOther ❑ Delta Depth of Grout Seal Type of Grout \ Irrigation ___Approx' De ❑ Eastern Surfa e"Seal Installediby Repair Work Done ❑ Type of Pump H.P.�� "` State Work Done \ (Nell Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 t 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 "` Number of living units: Number of bedrooms 1. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal I Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/siie FILTER BED ❑ Distance to nearest: Well Foundation Property Line r I SEEPAGE PITS ❑ Depth Size Number { (" SUMPS ❑ Distance to nearest: Well Foundation Property Line i 9 DISPOSAL PONDS ❑ r l 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 j rules and regulations of the San Joaquin Local Health District. fr, 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 �J 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 foil Ing:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- ki tion laws of lif rnia." The appli t m st call for It eq ed i C plate drawing o v rse side. 1 Signed L11' Title: 'G� Dater FO DEPARTM NT USE ONLY Application Accepted by Date /U -a - 7 Area I 3 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 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED BY DATE PERMIT N0. INFO + EH 13-24(REV.5165) EH 1426 ✓J