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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. l Job Address City U�{ Lot Size pM Owner's Name , L4 LW '34Ef/ � Address / � ?�t(�� !�[l! Phone Contractor (kala"-fAL Address License No `7— Phone ^'- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER *110,6%Ar� �� 2 ,-. —" !S?QNCE T1�fEARESTEWa DISPOSAL Ft D. R(0P FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`i Public ❑ Other n Delta Depth of Grout Seal Type of Grout rrrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by *.. epair Work Done 11Type of Pump 7;C"., e-;. ".P. � � � State Work done._ Well Destruction ❑ Well Diameter It'!W Sealing Material [top 50') -- Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION l I DESTRUCTION ! I (No septic system permitted if,public sewer is [ available within 200 feet.) \\\71 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 4 SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 11 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number —SUMPS . 0- Distance to nearest: Well Foundation __ .Property Line_ DISPOSAL PONDS ❑ �Jz — 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 Dikrict. Home owner or lice ed 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 pars in uch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the folio in . "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 ia." The applic t call for all requ-a inspe_tio omplete drawing on er a ide. Signed X Title: Date: FORD ARTME USE ONLY Application Accepted by q0 Date Area f Pit or Grout 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 ..- - __ � - TAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. 11VF0 CASH 4 r EH 13-24 MEV.i/N 5] 'EH 14-28 �� `��b�0