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APPLICATION FOR PERMIT SAN JOAQUIN LOCALMEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)'466-6781 PERMIT EXPIRES 1 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. Job Address � � yG/ f S �� f . f City i�J;N Lot Size PM Owner's !Name /� �////��{ L n y Arlddressq�✓�cy K,Z11'-5 J7 _ Phone Contractor's Name 1� / U S Y L69>el / 2,7 /`�Z� , '" 2 3 / Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION lk� SYSTEM REPAIR a— OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ,Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 El Irrigation r Type of Grout , pp ax. Depth 1:1 Eastern Surface Seal Installed by Repair Work Done Type of Pump H,P.�S` State Work Done Well Destruction ❑ Well Diameter - � _ Sealing Material (top 5011 Depth Filler_Material-(Below_50-1)_-. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .r. -available within 200 feet.) Installation will serve: Residence Commercial'—"' .Other I Number of living units: Number of bedrooms u 1 Character of soil to a depth of 3 feet: _ Water table depth s > SEPTIC TANK F1Type/Mfg y,Capacity - No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal a Distance to.nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines f Total length/size FILTER BED _r. [1 Distance-tanearest:,,,,„,;,�1Nell_ foundation Prope j rty-L-1ne SEEPAGE PITS ❑ -Depth t s -+ p � Sizes � �. � � Number p SUMPS ❑` Distance to nearest: • Well '1Foundation�L , 1 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 agents 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."Contractors.hiring or sub-contracting signature certifies the foil ng: ertify that Int performs of the work for which this permit is issued,I shall employ persons subject to workman's compensa- , tion laws of alifarnia," The applic nt m II or all r . Com -awing on r side. G Signed Title: Q.vtd Date: F DEPARTMENT USE ONLY II Application Accepted by Date_b0 Area ��j�� D Pit or Grout Inspection by Date Final Inspection by 'L� Det Additional Comments: a ❑ Stk 4664MI ❑ Lodi 369-3621 t ❑ 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 \ CK 4 INFO AMOUNT DUE `AMOUNT REMITTED GASH RECEIVED BY DATE' PERMIT"NO. EH 13-24+ EH 1425(REV.10!83) _O l� 4