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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 18652 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -� Job Address 3 Q cJ A cl �A/G O A d- City JLV Lot Size S 4 C fz-ES PM Owner's Name 11J, iAM v i L-s Addressg 3 / ,3 7Z d Phone - Contractors: TAR i 4 v'-5 nVSAddress Q &J -CSa,,,4)66 License No.2-5�(34/3 Phone 66 -96a? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ME T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKi � SEWER LINES DISPOSAL FLD. 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 Weil Casing ❑ Domestic/Private ❑ Gravel Pack------❑-Tracy----, Type of Casing Specifications ❑ Public l, ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation * ,.� --Approx- Depth ❑ Eastern Surface Seal Installed by `t Repair Work Done 0- Type of-Pbm`p 1 H.P. State Work Done 4 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 `•` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ REPAIR/ADDITION)4 DESTRUCTION ❑ (No septic system permitted if public sewer' �i 1 r-available-within 200'feet:j-; Installation will serve: Residence zCommercial_ Other e' 'Number of living units: Number of bedrooms � " 1 k Chraracte' of soil to a depth-of-3 feet: �4NW ''Water table depth f SEPTIC TANK Type/Mfg Capacity_ /.2inO C.L No. Compartments PKG:•TREATMENT PLT. ❑ � a / I tMethod of Disposal -.� Distance to nearest: Well "FoundationProperty L Me - j,/ 1 • 4 ��r �..- t LEACHWG:LiNE No. & Length of lineslength/size f A `• FILTER BED ❑ Distance to nearest:-----Well ---=--- Fdundation Property Line tk SEEPAGE PITS Depth �' ` Size .,-1 Number SUMPS ❑ 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 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."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." f The applicant ust call r all requi inspections. Complete drawing on reverse side. Signed Title: Date: J "•� _ .. �. -..� - _ IFID DEPARTMENT USE ONLY Applicationk Accepted y Date ' Area ® h Pit r Grout Inspection y Date Final Inspection by Date r Additional Comments: ❑ Stk 488-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I i Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazekon Ave., P.Q. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY _ DATE PERMIT''NO. + EH 13-24 -Lk EH 14-26 IREV.i/e51 --7c=) CA/9V bT17;6 - r