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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE'-T ON.AVE„ STOCKTON, CA y 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-pekmiVto 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 iv City . L Lot SizeSkirctsPM Owner's NameO 10-V4 1 0 ik. Q S Address <5 � � Phone Contractor laeLA e011Address o License Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Open Bottom _ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation _--Approx. Depth I 1 Eastern Surface Seal Installed by _. 1 f- Repair Work'Done C Type of Pump H.P. State Work Done + Well Destruction ❑ Well Diameter Sealing Material (top 50') C Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIFUADOITION I I DESTRUCTION I I (No septic system permitted if public sewer is 'available-within 200-feet.r i Installation will serve: Residence L� Commercial_ Other Number of living units: Number of bedrooms. 6' Character of soil to a depth of 3 feet: Water,talile depth SEPTIC TANK Cf Type/Mfg .C V-Z a Capacity 0-0'—-__'N6. Compartments o PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 'Foundation ° f3 Property Line LEACHING LINE '11 No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well k Foundation' Property Line SEEPAGE PITS IArDepth _ _Size 1C. Number SUMPS Ll Distance to nearest: Well Foundation Property 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 District. ; s 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 California." " The applicant m t call for qWreq its ctio . Complete drawing on reverse side. Signed X Title:-_ f• f1i � fl'- Datw — O FOR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by / j Date 1~ Final - -1nspection by Date Additional Comments: r El 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.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CCK H RECEIVED BY DATE PERMIT*NO. EH 3-24+ EH l4-Zg;REV.i i rs 51