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APPLICATION FOR PERMIT x SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. �" j Job Address y Citq! Lot Size PM Owner's Name` TK YetiIF 7 rl Phone Contractor's`NameT .=- iE6 se'No J " Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I i 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 —5-bp,, Bottom _❑ Manteca —Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public P ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —.—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 ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial-Wither Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ty o. Compartments PKG. TREATMENT.PLT. ❑ [ Method of Disposal Distance to nearest: Well Foundation Property Line r _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to clearest: 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'perfarmance of the work for which this permit is issued,I shall not e ploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ce as the following: "I. ify that in the performance of the work for which this permit is issued, I shall employ persons subject to•workman'a compensa- tion la f California." The applicant call for all qu ed ins ction . Co lets drawing on r verse side. Signed Title: _11,5 ) Date: . EP ENT USE ONLY + r Application Accepted byP9 0� Date Area Pit or Grout Inspect! n e Final Insp tion by Date j, Additional Comm ts; `�a! r I ❑ Stk 466-6 El Lodi 3W3621 M teca 823-7104 ❑ Trac 835639 Applicant Ret a1 c pies to: Environmental Health Permit/S_ ices 1 1.E. azelton Ave., P.O. Box 2W9,,Stk7,CA 95201 EEE AMOUNT DUE AMOUNT REMITTED PK RECEIVED BY DATE PERMIT'NO. INFO CASH § + EH 13.24(REV. 10/0 / ,'71�J� •5••,� t EH 1428