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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 TYEAR FROM DATE ISSUED iComplete 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. / Job Address 90�� /�o tl -, City Lot Size /40 1442-e-5 PM Owner's Name/&Oaf d/ r'I if '7 Address 6aW'2. dS akye_ Phone`CC& _3717 on � Contractorf!)641f&&0970'6. Addfess,¢4 2VAX(?ft' License NoAY 6 4?S Phone —6 1__f TYPE OF WFLLlPUMP: NEW WELL `(. WELL REPLACEMENT �' DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /O ff SEWER LINES Zbj�f� DISPOSAL FLDJd If PROP. LINE j FOUNDATION 804- AGRICULTURE WELL —� OTHER WELL O" PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J<Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing hYC Specifications glee`S 1,6 0 I-1 Public ❑ Othe Ll Delta Depth of Grout Seal Type of GroutC�7T1Prlt 7 i I I Irrigation raUc. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material Malow 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is - - available within-200-feet.) • - Installation will serve: 'Residence— Commercial— Other Number of living units Number of bedrooms ' I 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 n %, Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line a SEEPAGE PITS i I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict- � , . _ -T 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,.1 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 1 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 ust c I for all req uir dins ctions. Complete drawing on reverse side. Signed X Title: / q r t',�Z�CD/' Date: fa,—/ F/ , � I FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit o .Grout nspection by 1 Date% �� Final Inspection by Date_'10/� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ -rr—acy 935-6385 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 CK RECEIVED BY DATE PERMIT NO. 1 • EH1U3-24'REV.1/H51 Ili �' •^� A EH -26 O � -!