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APPLICATION FOR PERMIT 'a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) g-030-UI 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. (.5`01 EJob Address �� O'� !?,D City L At/ ��_ Lot Size PM Owner's Name �-�3 P� A r- -ol-Address L A'f4 '1 8 f e Phond4f`gnt.'Zy ContractO 01011 1 A1LL6✓f)N4I( dfess�� N /`A� e 0 License NogJ eg3q- Phoneg/6 5XI TYPE OF WELL/PUMP: NEW WELL WELL R PLACEMENT ❑ DESTRUCTION')&, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ® bte6L41 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 A ❑ Industrial ❑ Open Bottom Pk Manteca Dia. of Well Excavation Dia. of Well Casing y ❑ Domestic/Private Gravel Pack ❑ Tracy Type of CasingSpecifications r I`l Public 171 Other F-1 Delta Depth of Grout Seal VAR! �� Type of Gmdut f!4—t �`,r I I Irrigation YAfift-$-..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction El Well Diameter Sealing Material atop 501 ' a�WP04f V1; Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 204 feet.l Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Q 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 i I 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', ander rules and regulations of the San Joaquin Local Health Di1trict. 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 parsons subject to workman's compensa- tion laws of California." The applicant ust call for all required 'nspections. Complete drawing on reverse side. pr Signed X Title: I A1`` 0 h 1 wf`� Date: 7- I _ FO EPA T E T USE ONLY Application Accepted by Date a Pit or Grout Inspection by Date r'a2 �� Final Inspection Date Additional Comments: 7-7 eyl(e ' 2Z- ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 f� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 952i<1 �01 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO `� ,ry``11 CAS�7H C . EH 13-24(REV.1 5) - '0 �s- V v 33�Z f�41 l f•r/l/7 EH 11-2e