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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I 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. I I Job Address �. S� �vu rpt- City Lot Size ACEI?aM Owner's Name r 2—p1 1)® Address Phone Contractor{ A j�►L"'� Address WO LZ &/A-License No.4aos—ao—Phone_�?a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ yv PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'r Specifications M Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by t _ Repair Work Done ❑ Type of Pump _ H.P. State Work Done !` Well Destruction Ll Well Diameter Sealing Material atop 501 If Depth - Filler Material (Below 50') } TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ESTRUCTION l I INo septic system permitted if public sewer is ! _ available within 200 feet.I L� r Installation will serve: Residence— Commercial Other Number of living units: l Number of bedrooms # Character of soil to a depth of 3 feet: 1� Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ ! s Method of Disposal i Distance to nearest: Well � , Foundation` '""'"""'^"-•'�Property'L'ine U/ 1f a � LEACHING LINE N—"tr-& Length of lines Total length/size/ FILTER BED ❑ Distance to_nearest: Well_"SIhD_..-. Foundation Property Line SEEPAGE PITS I I� Plh Size= Number SUMPS ❑ Distance to nearest: Well _ f=oundation .42D Property Line DISPOSAL PONDS ❑ # e I hereby certify that I have prepared this application and that the'work will'be done in accordance with San Joaquin county ordinances, state Iaws, 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 M employ any person in such manner as to become subject o,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- t n Californi i ' t,... .�.,.�—.•r......,� ----.�.-=-�• i � r The applica t t c for I re (red ' lata drawing on r rsa side. 71 tie Date: T, FOR DEPARTMENT USE ONLY Application Accepted by ` t Date Q Area ! l f fit or Grout Inspection by fr- (9AW, 1 ..Date Final Inspection by 7 Date I Additional Comments: E7 Stk 466-6781 ❑ 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 t INFO AMOUNT DUE AMOUNT REMIT-rC K RECEIVED BY DATE PERMIT'NO. f i EEH 13-24 H t4-Z8 IREV.1/115) 70 .1't , � 3 O I - r r