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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE; TON AVE., STOCKTON, CA Telephone {2091 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 0.1 e_¢ f City AA5..t T e_Q�1, Lot Size a PM Owner's Namek b tr_ O� . s r Lo—Address Phone C- Contractor yam_- r Address�;Z3 Ki c S—?P_icense No. fo I Y/D Zr phone a`2-S'1 S-3S 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9rAA01-'1 1 Ot',n--) DISTANCE TO NEAREST: SEPTIC TANK-t-21 C300 SEWER LINES DISPOSAL FLD.AZA- PROP. LINE-t FOUNDATION AGRICULTURE WELL OTHER WELL/J_ PITS/SUMPS/SLL# INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr ❑ Industrial ❑ Open Bottom LR'manteca Dia- of Well Excavation_g Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing IVC Specifications ❑ Public ( Other, ❑ Delta Depth of Grout Seal Type of Grout©l� T I I Irrigation -i;CApprox. Depth I I Eastern Surface Seal Installed by bQT"a� 1 e Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 50') —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION l 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 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 ❑ 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."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 C ifornia." The applica ust call for al squired ' pect' omplete drawing on rev' side. /1 Signed X Title: /.�� Date: ^ FOR DEPARTMENT USE ONLY Application Accepted by Date \ Area r � Prueq Pit or Grout Inspection by Date Final Inspection byDate y Z I 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma tete 823-7104 ❑ Tracy 5-6385 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.iin5Y IY1 Q / M ry)� EH 14-26 ! V AL 1