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�- a o 4 s Sa ra-4 cc:1�, _ r )�p APPLICATION FOR PERMIT `I 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /� Job Address ,,�G�oo /1 446.x/ A?. -?!PS JA,-A&,4 City Lot Size `5-0?%/O 6 PM Owner's Name V L 4,W A CO®-'"Z e s' Address Sy/7 /4elS,4 C 7- fO CG'S 17) Phone S Contractor f s�1/'E/2,15& -J ,S61V1 Address 90 IV, W-14rav 4:-'A!f icense No. Phone Y —9L 6 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done O Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 () Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A DESTRUCTION I I (No septic system permitted if public sewer is p available within 200 feet.) Installation will serve: Residence X Commercial__ Other 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 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 SEEPAGE PITS 11 Depth /Z Size 4� �/� _ Number SUMPS (;K Distance to nearest: Well 90WO.. Foundation /A r Property Line �S DISPOSAL PONDS ❑ 1 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 N 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 l 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." The applicant must call for/all required inspections. Complete drawing on reverse side. Signed X Title: Date: F, PARTMENT USE ONLY Application Accepted by /f � _ .. 'tom Date Area ZZ Pit or Grou4'Inspection by Date Final Inspection by Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.i i x 5) EH 14-28