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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA No WAV u, Telephone (209) 466-6781 y /! PERMIT EXPIRES TYEAR FROM DATE ISSUED VJ (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 describe . Th1t� ation is e 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 Lo Health District. Jbb Address �`� � ) S "� ad v _ _ City 5`Q �Odd Lot Size PM Owner's Name Z�\Wlti >2yLt�tllta Address Phone �� SS Contractor Address License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ _ OTHER -13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL__=f:f:'__ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAS-CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca--- Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications M Public Ll Other 171 Delta Depth of Grout Sea]" Type of Grout a — I I Irrigation _._Appy epth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION ( I DESTRUCTIO I INo septic system permitted if public sewer is vailablett�ithin 200 feet.► Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms V Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation Property Line 4 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 ❑ 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. 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." Contractors 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 appiic must call for allVquired—iftp-ections. Complete drawing on reverse side. f igned X _ Title: Date: FOR P ENT USE ONLY f7i a� Applicatio Acreptedby ._ s .awn Date � � � Area Pit or Grout Inspection by a Da FinaIII spection by Date Additional Comments: } _ J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 5 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 CK 0 RECEIVED BY DATE PERMIT'NO. 414 + EH 13.24 1REV.r/x 51 EH 1428 OD �5 ✓ 8r.,We/ S�r-