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APPLICATION FOR PERMIT -. I� 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. k I Job Address r�S /`1Y�T CAVAAada Lot Size x/u� PM Owner's NameAddress Phone i �fQQ Contractor Addiess icense No.' 6 Phone 7 0049 TYPE OF WELL/PUMP: to, NEW WELL ❑ WELL RF-Pi ArFmENT- ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications W 1-1 Public 1=1 Other 11 Delta Depth of Grout Seal Type of Grout . I I Irrigation _'Approx. Depth l I Eastern Surface Seal Installed by (. Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth - Filler Material (Below 50') {�1 TYPE OF SEPTIC WORK: NEW INSTALLATION 41 REPAIR/ADDITION i.I DESTRUCTION (No septic system permitted if public sewer is i .t available within 200 feet.) installation will serve: Residence_ Commercial_ Other r 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 5 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 it i 1 SEEPAGE PITS 11 Depth ' Size Number f SUMPS f ❑ Distance to nearest: Well f=oundation r Property Line DISPOSAL PONDS ❑ ►.fes " 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. 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 certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall-employ persons subject to workman's compensa tion laws of California." y The applic ust call f all a it d ' ns. Complete drawing on reverse side. Signed X Title: V.Ll �11 Date: - F -DEPARTMENT-USE ONLY ' * ! ~# �~ Area Applicatiori-Accepted by i — Date it 5 l E Pit or Grout Inspection by Date f=inal Inspection by Date f 5 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 r1 INF MOUNT ^DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. ' + EH 3-24 IREV.ri»59�141 EH 14-2g /_ 3�� r