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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 'FROM DATE ISSUED ' (Complete in Triplicate) Application is heieby 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. Job Address City 7t Lot Size PM Owner's Nam 1^ta 7" IGfJ its4�Addre L) Nr �ec� Phone Contractor �!" �C/-� Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE 1� FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA-–CONSTRUCTION SPECIFICATIONS ❑ Industrial , ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑•Gravel Pack C7 Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _-Approx, Depth I 1 Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done _ IE' Well Dest on ❑ Well Diameter Sealing Material (top 501 Z�Z !� Depth Filler Material IBelow 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet. Installation!Lill serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character F soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �i PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line dE' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED I ❑ Distance to nearest: Well Foundation Property Line �I SEEPAGE PITS I 1 Depth Size Number SUMPS 11 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 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 ownerlor 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 p1erson 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 1he performance of the work for which this permit is issued, !shall employ persons subject to workman's compensa- tion laws of California." The gippcant!must call for all required inspections. Complete drawing on reverse side. Signed X CA-iza- Title: QV7IPJY Date: - QR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by I / Date 07 Additional Comments: Ak P ❑ 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 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED K Off EH13-24(REV RECEIVED BY DATE PERMIT NO. t .t�N51 r��L ,3 � 4 -2 EH 14-26S� ,