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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v w (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. (A as 0-14 Off_J Job Address ` ► e City "" Lot Size ACf �11� Owner's Name Address V, �dd` �vy, PhoneF Contractor L_ &YWJ Address �f"!L� f�+ �-`""license No.0 ^TYPE OF`WELGIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I [ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy..w Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -i-Approx. Depth ❑ Eastern .Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR]ADDITION ❑ DESTRUCTIOIX {No septic system permitted if public sewer is IF vailable within 200 feet.) v 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 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ ,. Method of Disposal - Distance to>nearest: Well-, ":Foundation Property Line ,;'y LEACHING LINEx. ❑ - No. & Length of lines_• y Total length/size It FILTER BED C1 Distance to nearest: Well � Foundation . Property Line 6-.,SEEPAGE.PITS f ❑ Depth A^... " Size Number . SUMPS`- '" 1 ti ?bisia a to nearest: Weil ��' .r foundation P#perty 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, and rules and regulations of the San Joaquin Local Health Districts .w r 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 followin '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 Californ The applicant must rr *ij'n�spections. Complete,drawing on re r5+3-s Signed X Title: Date: e h FOR DEPARTMENT USE ONLY 4 Application Ace ed by ` Date Area Pit or Grout Inspection by Date I Firnal Inspection by Date Ad ' ional Comments: t. Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca '&M-7104- ❑ Tracy 835-6385 App nt- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ 4 FEE AMOUNT DUE AMOUNT REMITTED' �-RECEIVED By DATE PERMIT'N0. INFO 0. EM 13-24 _ err + EN 14-28 RREV.1/H 57 7 � .