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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r t City A4W- Lot Size V'9 J4, M6iL PM Job Address A' 4ALAV' Owner's Name j�A AddressV 7�'�7� ��i, '"°'�� - Phone Contractor JF�. Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ it DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD/Z4!-�PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS g if ❑ Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (I Public ❑ Other n Delta Depth of Grout Seal Type of Grout `- y I I Irrigation —--Approx. Depth Eastern Surface Seal installed by 6 Repair Work Done 13 Type of Pump 44-P. State Work Done _ l Well Destruction Well Diameter !f (0 Sealing Material [top 501 Depth Jr Filler Material (Below 50'1 0 -- O TYPE OF SEPTIC WORK: NEW INSTALLATION [ 1 REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public.sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r 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 l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Yaws, and 1 hereby certify p PP Y I have that pre rr&s 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 ll 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 pirsons subject to workman's compensa- tion laws of California." The applican PSI call for al a d i pections. Complete drawing on reverse side. f Signed X Title: Date: I FO EPARTMENT USE ONLY Application Accepted by Date ell, rea G Pit or Grout Inspection by Date Final Inspection by Date WQ7- Additional Comments: ❑ Silk 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO +.EH 1 -24(REV.t i x 5) {3 5L5,7EH 144-28 r.,7 Lrsq-