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ti APPLICATION FOR PERMIT , IVA SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7YEAR 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. 1 Job Address 116 !C�l City Lot Size PM Owner's Name �_ °l Ld4w l Address apt. Cta 7 0� Phonexi Contractors ✓� {/� 1�.._._I t "ddress .� License No.�;Phone TYPE OF WELL! UMP: NEV( ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CP PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE :..,,,_TYRE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 111 Irrigation " --Approx. Depth l I Eastern Surface Seal Installed by _ . r Repair Work Done ❑ Type of Pump _�_ H.P. State Work Doe F� - �� Well Destruction � Well Diameter Sealing Material )top 50') " Depth p 6V ler Material'(Below,50') ai3,.l — � TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will;serve: Residence Commercial W__ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet.! Water table depth r k 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 L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that t 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: 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 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- lion laws of California." The applicant must II for all required i specti omplate drawing on"reverse side. Signed XTitle: Date: 704 l r# FOR DEPARTMENT USE ONLY `} / Application Accepted b'y l`rf'y' \ Date �, / Area Pit or Grout Inspection by Date Final Inspection b 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 INFO AMOUNT pUE AMOUNT REMITTED CASH CK 11 RECEIVED BY DATE PERMIT'NO. �.EH 13-24 IREV.r/x 5) EH 14-26