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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 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. t Job Address J a� 17&V/7/!+F[, City ZIAldeA) Lot Size PM Owner's Named Address `"' ( W Phone Contractor T 4FV/ /1A1V3Z�Address •(IT A&e4dLicense No- TYPE o3 - TYPE OF WELL/PUMP: NEW WELL 14 WELL REPLACEMENT C3 DESTRUCTION ❑ Phone 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 ; a ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation w Dia. of Weil Casing to i L1 Domestic/ ❑Gravel Pack ❑ Tracy Type of Casing Specifications .IRS f 1 Public Cl Other C! Delta Depth of Grout Seal r z / Type of Grout Zme i _. X Irrigation 490'_Approx. Depth I I Eastern Surface Seal Installed by- Repair Work Done ❑ Type of Pump Ft.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth • Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1") REPAIR/ADDITION I.I DESTRUCTION I I (No septic system permitted if public sewer is � available within 200 feet.) (.� I Installation will serve: Residence_# ommercial— Other Number of living units: Number o bedrooms ,n Character of soil to.a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal -Distance-to-nearest:- W Well'" '" " Fouridafion'""'� "" ''6—Property Line LEACHING LINE ❑ No. & Length of lines Total length/size -I FILTER BED ❑ Distance to:nearest: W II Foundation i Property Line SEEPAGE PITS.. I I Depth r Size Number 1 SUMPS 1-1Distance to'nearest: Well Foundation 'Property Line } DISPOSAL PONDS ❑ f' 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 D�trict. cr3, 3 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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- tionlaws of California." Thea ica ust c I I required inspections. Complete drawing on reverse side, Signed Title: Data: J,� FOR DEPARTMENT USE ONLY q .r- Application Accepted by Date Area a Pit or Grout Inspection by Date FinalInspaction by Date c . , Additional Comments: �,,_ �t c,K�L. /D �qA_3 ❑ Stk 466-6781 ID Lodi .369-3621 1ianteca 3-7104 ❑ Tracy 835-6365 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, 4 ..EH 13-21 iREv.i/n 51 EH t4-28 '