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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. w: (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 y, Local Health District: Q Job Address • J • &/ E U2,17-7— D- City Z Al OrEALot Size �y A C PM � Owner's Name W •7 P Al Address f d �. s• ./ Phone v •V 3 rr t. Contractor VAI 610 f frRddress ZZ lV' fS� LrS1� y I� + ` Q' - ,License No. Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,Vo..,.—DESTRUCTION ❑ PUMP INSTALLATION ❑ ��SY,STEM REPAIR} El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a DISPOSAL FLO. 'PROP. LINE FOUNDATION AGRICULTURE WELL'S t OTT ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION AtCI CATIONS i f ❑ Industrial ❑ Open Bottom ❑ Manteca �. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public..r� ❑ Other _ ❑ Delta Depth of Grout Seal I Type of Grout EJ Irrigation __—Approx. Depth LJ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. l State Work Done I IL Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501 t v v ✓ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) b Qnstaliation will serve: Residence.Commercial_ Other Number of living units:_/__ Number of bedrooms Character of soil to a depth of 3 feet: U L Water table depth SEPTIC TANK ❑ Type/Mfg Capacity«10 y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation A/9 O Property Line .`s0 7— X ' l LEACHING LINE Q No. & Length of lines2:— r L MoE6 Total length/size lyw ) FILTER BED ❑ Distance to nearest: Well 6F Foundation .9,06 fi��operty Line SEEPAGE PITS ❑ Depth `1�rF �T�Size Number j SUMPS ❑ Distance to nearest: Well . �OIJf Foundation 1 10 0 Property Line DISPOSAL PONDS ❑ 1 I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I 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 persons subject to workman's compensa- tion laws of California." The applican s call for al r iced i s ti ns. Complete drawing on reverse side. g Signed Title: N%�Z:Xg-� - Date: J� EPARTMEfYT U E ONLY Application Accepted by Date [ �/ Area f 7 it r Grout Inspection by ate 110^ gal Inspection by [A - n Date��Vlp s 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 it FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. INFO ' l + EH 13-241REV.1/e5) �a. 0� �f.S KV JI B/o EH 1426 I i