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APPLICATION FOR PERMIT 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) 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. c , f Job Address L l�u)«a J 4ey- -1�- City 1--c)0 Lot Size PM Owner's Name n Address qNX1r�r'a� &-• phone / Contractor's Name O License No. + _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION 11 —SYSTEM REit PAIR ED El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATiaN AGRICULTURE WELL+l OTHER WELL_____L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u ❑ 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 4Grout Seal Type of Grout ❑ Irrigation .Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State or Done 417 Well Destruction Well Diameter Sealing Material (top 501 ; Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic sTstem permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other + + Number of livingunits: Number of bedrooms Character of soto a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i . Capacity No. Compartments PKG. TREATMENT PLT. ❑ IMethod of Disposal ' Distance to nearest: Well Foundation Property Line I` 1 ► LEACHING LINE ❑ No. & Length of lines 1 Total length/size FILTER BED ❑ Distance to nearest: Well Foundati nProperty Line I � t SEEPAGE PITS ❑ Depth Size I l Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS 11 „ ,,a L_ 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California.” Contractors hiring or sub-contracting signature certifies the following: 11 c rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion I o alIfornia." Thea plica t ust callr all required inspections. Complete drawing on reverse side. Signed Title: ENj rry cri�2 Date: 10Q L FOR DEPARTMENT USE ONLY Application Accepted by Date Area 0/ 2— f Pit or Grout Inspection by Date Final Inspection by _ Date O U Additional Comments: ❑ Stk 466-6781 KLodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Envirorlmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �,vll.l4 FEE INFO AMOUNT DUE AMOUNT REMITTED K R RECEIVED BY rD�ATE�1.� �-P,E"RMIT"NO. + EH 13.24 MEV.10/831 /� d✓ V 1SCSI',, •'Y EK 14-28 Lf