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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. TMs 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. 36, ©00 kl.,SSoK " Job Address IrC4 fA 3p 9.41&- opw 5:J. A C, City 7'192Z- Lot Size PM Owner's Name AIW Ax,,Wh C Address SAiWV Phone Contractor's Name ��' License No. YS�'- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ` PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout !� 13 Irrigation Approx. Depth Eastern Surface Seal Installed by V Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-I!L Commercial_ Other Number of living units: Number of bedrooms_Z Character of soil to a depth of 3 feet: gmdeyx Lids&M Water table depth d? SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well W1,4 Foundation Property Line /p V1% P 0 LEACHING LINE Q' No. & Length of lines ��Tntal length/size .f FILTER BED d Distance to nearest: Well� IFounda_tiog yo' Property Line GX30 f�t/f SEEPAGE PITS ❑ Depth Size 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 F' neer employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contlWAWO certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ�ns tion laws of California." The applicant must call r all required inspections. Complete drawing on reverse side. Signed Title: FOR DEPARTMENT USE ONLY 1 Application Accepted by Date "` Area Pit or Grout Inspection by Date Final Inspection by Date~ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT �DDU}E AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"N0. +EH 13-24(REV.10/836 - p.� EH%28 ;101f 0..7