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a APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ± 4 Telephone (209) 466-6781 t PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installthe 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. s Job AddressCity Lot Size PM r Owner's Name' Address �`- 64f e C Com`"�� Phont X57 Contractor..Y4 cc' - AddressF `k- L;&- = 4�`�oY License No. Phan TYPE OF WELL/PUMP: NEW WELL ❑ WELL-,REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Yt__ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ff FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout _ I I Ifrigation Approx. Depth 1 I Eastern J Surface Seal Installed by _ Repair Work Done ❑ Type of Pump. -;� H.P. State Work Done � lT Well Destruction ❑ Well Diameter Sealing Material {top 50`) Depth ' Filler Material (Below50'1, TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION 1.1 DESTRUCTION I I INo septic system permitted if public sewer is ry i. available within 200 feet.) ' Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms 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: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth r Size Nu'm'ber i SUMPS 0 Distance to nearest: Well { Foundation Property Line i 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 Di%trict. 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, 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 t all for all req 'red inspections. Complete drawing on reverse side. q Signed )�__- , _ Title:,. Date: L l - _FO.R PAR ENT USE ONLY 6 Application Accepted by - Date 2 amu" Area 'Y Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED I K 11 CASH RECEIVED BY DATE PERMIT'NO. +.EH 1324 1R£V�.Iiv EH 14-2e as