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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 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. s Job Address, 6910 Haight bad 330' X Ci Lot Size PM Owner's Name XR. Ctyde Vaiani Address X 18 Phone Contractor's Name .6 et License No. - TYPE OF WELL/PUMP: NEW WELL ❑ - Phone WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKDISPOSAL FLD, FOUNDATION �Q SEWER LINES * PROP. LINE —4-of AGRICULTURE WELL _X_ 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 N ❑ Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing F-1Public ❑ Other I EJ Delta Specifications Depth of Grout Seal Ll Irrigation of Grout Irrigation —-Approx. Depth ClEastern Surface Seal Installed by Repair Work Done ❑ Type of Pumps H.P. -State Work Done Well Destruction JP Well Diamet(6 Sealing Material (top 50'1 Depth Filler Material (Below 50'1 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— I Commercial— Other 1 Number of living units: Number'of bedrooms Character of soil to a depth of 3 feet: k SEPTIC TANK 1-1Type/Mfgtable depth Type/Mfg 1 Ca act PKG. TREATMENT PLT. ❑ p tyNo. Compartments Method of Disposal Distance to nearest: Well Foundation Property Liner r � t LEACHING LINE ❑ No. & Length of lines { FILTER BED Total lengthlsize ❑ Distance to nearest: Well Foundation Property Line i PT I SEEPAGE PITS ❑ Depth p - Size y SUMPS El Distance to nearest: Well Number Foundation Property Line DISPOSAL PONDS F1 ' 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: "I certify that in the performance of the work for which this permit is issued, I shall employ t tion laws of California." p p y persons subject to workman's compensa- tion The applican at call for a requ red inspections. Complete drawing on reverse side. Signed i Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �( D Area Pit or Grout Inspection by4 Date Final Inspection by Date # Additional Comments: 1 ❑ Stk 466-6781 "Lodi 369-3621 1 ❑ Manteca 823-7104 ❑ Tracy 8366-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C INFO RECEIVED BY ;DATE PERMIT"N0.+ EH 13-24 IREV,TOla31Ek 1426 �5. t, ��.��.,