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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 r (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address Jl _ � G�r�'/' City Lot Size PN! a_ 00 Cv Zz( � Yl2a s4 s-6-tea Owner's Name { Address Phone Contractor CQ Y Address td z�✓=icense No. Phone ��sr "g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: "SEPTIC TANK SEWER LINES _,PROP, LINE FOUNDATION AGRICULTURE'WEEt OTHER-WEL'1"`/S' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 4,❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of..Casing Z r hV �-- Specifications ❑ Public 11500ther ❑ Delta Depth of Grout Seal J --Type•of Grout r ` ❑ Irrigation —Approx. Depth ❑ Eastern- --, Surface Seal Installed-by Cr` J1 1A Z Repait,Work Done ❑rr Type of Pump H.P. State W k Done c\ V Well Destruction ,�f WeH Diame r i Sealing Material (top 501 I Depth Filler Material iBelow 60') TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION ❑ -,DESTRUCTION ❑ 1 N septic systempermitted if public sewer is 4 available within 200 feet.) tiN Installation will serve: Residence— Commercial_ Other Number of living units: E Number of bedrooms f F I Character of soil to a depth of 3 feet: — i I Water table depth } , SEPTIC TANK ❑ Type/Mfg Capacity No.'Compartments PKG. TREATMENT PLT. ❑ -;d Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of 1ines. Total length/size ` FILTER BED ❑ Distance tb'nea'rest: Well I Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well i Foundation Property Line DISPOSAL PONDS ❑ 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. (° r h, ;r 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 Califor The applicant mu I for all require "nspe Co ete drawingt on reverse side. Signed Title: 4..fiZ �br Date: - k r— .�.r-rte .✓.. �...... + -rte i Q 1)EPA TMENT USE�QNLY�'�'-"" —•"'�'�"'"" Application Accepted by r DateArea Pit or Grout Ins c' y Date final Inspection b Date Ad nal Comments: .40 Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eco 8 ,71104 ❑ Tray 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 CK RECEIVED BY DATE PERMIT"NO. + EH14-24(REV.1/B 5} 0i EH 1428