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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District -7W JV s Job Address S' da V 1J mo w' d ' M S'City ��VC,k-70� Lot Size PM Owner's Name P. • �1� _S Address go W a ft.A kc)Phone Contractor h Address Q 1 L c nse No�-gQ-3%31Phone ' TYPE OF WELL/PUMP: NEW WELL SWELL REPLACEMENT LIDESTRUCTION ❑ PUMP INSTALLATION Gr we l SYSTEM REPAIR ❑ OTHER''❑ f DISTANCE TO NtAREST: SEPTIC TANK A_Oft C SEWER(LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f / ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation JD Dia. of Well Casing ❑ Domestic/Private J$Gravel Pack ❑ Tracy Type of Casing S tG Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 7Q!4pprox. Depth ❑ Eastern Surface Seat Installed by_ Repair Work Done ❑ Type of Pump H.P. Q— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 tj TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (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 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 ❑ Depth Size Number- SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 5 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 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."Contractors 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 applicant ust call for all required inspections. Complete drawing on reverse/ ssidle. Signed Y /�/n AAA_9 Title: �P_ /!-_ Y k e_S Date: ey 7 -POP14Z92ARTIVIENT USE ONLY Application Accepted by C"A 15�a,aSI AAA__; � Date �r f _.. Area Pit or Grout Inspection bcy� f-Date r�Final Inspection by�" ��1-r Date _�/f /2n Additional Comments: U C WI L, OU�z-� '! A !' ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy $35-6385 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO 7C /� CASH +EH 1324(REV. 6) Q t LJ� �`S-7 —1,� r _ EH 1428 1��r\ ! S ! ap