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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH 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 y ,. � City Sfut D Lot Size Igo X iU4 PM Owner's Name AddressI LI`-�3 nr v;1 l�z V , I'1 L Sfii� J�fuN Phone C`/S' D��/ -1-ASCO EnH167y CltiiS-fi;, Contractor Se,v�"cs Address 'FYI r, v License No. PhonErL� �--�-=-9 Y53� -�,��0> �r ') �o%zl"b`l0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 '� ❑ Domestic/Private Dia. of Well Casing Gravel Pack ❑ Tracy Type sing_ p�� e Specifications ❑ Public ❑ Other ❑ Delta De of t Seal ❑ Irrigation nn I Type of Grout fcrf( l r �Approx. Depth ❑ Eastern Su e S Installed by w cam•- y- Repair Work Done ❑ Type of Pump >7/T H.P. State Work Done Well Destruction Well Diameter " Sealing Mat r I—* 9 Ito 0'1 P ,.,:T / -1y1L I Depth Filler Materi ow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION STRUCTION ❑ I septic system permitted if public sewer is Installation will serve: Residence_ Commercial available within 200 feet.) Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �u LEACHING LINE O No. & Length of lines FILTER BED E) Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth Size \ Number ❑ Distance stance to nearest: Well Foundation `,, DISPOSAL PONDS ❑ Property Line ` rules and regulations of the San Joaquin Local Health District. 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 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 persons subject to workman's compensa- tion laws of California." The applicant must 4 for all re fired in ctions. Complete drawing on reverse side. Signed — Title: Date: F WD'EP T USE ONLY Application Accepted by .�/ - Date - - Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O 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 FEE AMOUNT DUE AMOUNT REMITTED CK# INFO CASH RECEIVED 8Y DATE PERMIT N0. + EH 13-2�(REV.i%e a� EH 142(3