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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) F 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. 1 Job Address Z3 le -1 AlCity Lot Size PM m Rf> s Address Owner's Name. Phone �8 /Contractor FLf:' Address Z Wj /4A1>EG .s rlicense No.�?' x7 ._—Phone SjG.t'-3q TYPE OF WELUPUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARESt-SE TANK SEWER LINES D SAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONS, CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom F`.❑.Manteca of Well Excavation Dia. of Well Casing Specifications ❑ Domestic I Private Ll Gravel Pack ❑Tracy Type�of Casing fl Public f 1 Other n Delta Depth of Grout Seal Type of Grout A: n I I Irrigation Approx. Depth 1 I ern Surface Seal Installed by i Repair Work Done LI Type State Work Done Type of Pump , ' !Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION)(1 REPAIR/ADDITION l',1=,DESTRUCTION l I (No septic system permitted if public sewer is I -, � '.N available within 200 feet.).,, 1 rt I f #=r installation wilt serve: Residence. �- Commercial—" Other' r �- ".' v Number-of F3ing'units: Number of bedrooms ,,., e-hWater table depth Character of soil to a- _Z 3 feet: S. .lb SEPTIC TANK tE�' Type/Mfg P�?- t'' — Capacity l a No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t� r �• ,�. u Distance to nearest: Well 12 4 Foundation_4 6; Property Line�_Zle /r LEACHING LINE No. & Length of lines - ` _ Total length/size-12-0 FILTER BED ❑ Distance to nearest: I Welt Foundations �--Propelny Line I �7 SEEPAGE PITS l Depth TS Size Number SUMPS L1 Distance to nearest: I Well S-19 Foundation '7S' Property-Li ne--- 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 s 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 compansa- tion laws of California." The applicant must call for all required inspections. Complete-drawing-on-reverse-side. - Y Signed X -,7--L- 'o, Title:. &MOL Date: v2 Y�'gf1' ti -DEPARTMENT USE ONLY " 1/)2 ,1 Date Z Area Application Accepted by _ Pit r Grout Inspection by y� U�', �Date off - 'Final inspection by .i !� r ` �� Date I l / � Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t{ Applicant- Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i s 3 to A s FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO { ' I ♦ EH 1124 IREV.i i 8 5' 1 G 'EH 14-28 11