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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601,E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r Y (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.;;;, NYU City Lot Size aAL PM Job Address � p �� Owner's Name l [.4wYiliO[!� f l` s 670,16 Address (03 —" Phoney /Contractor's Name 6 License Na. 30�5?-1 Phone 1735'33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t 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 Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---4pprox.'Depth ❑ Eastern Surface-Seal Installed by Repair Work Done ❑ Type of Pump - H.P. State Work Done Well Destruction ❑ Well Diameter- Sealing Material {top 501 Depth Filler Material {Below 501 s i TYPE OF SEPTIC WORK: NEW INSTALLATION' .,.REPAIR/ADDITION ❑ DESTRUCTION❑ (No septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence ✓Commercial_ Other r i Number. f of living units:� Number of brooms.— r Character of soil to a depth of 3 feet:', VA Water table depth SEPTIC TANK k" Type/Mfg apacity /*2 Y_Q No. Compartments �^ ° .- PKG. TREATMENT PLT. ❑ r Method of-Disposal Distance to nearest: Well 16.0 Foundation _ ..-- Property Line q' LEACHING LINE" — W' F'No: Length of lines dI Total length/size - f FILTER BED ❑ Distance to nearest: Well 1 Foundation ( Property Line�� �. - SEEPAGE,PITS Depth Size � �"- `"�- Number SUMPS ❑ 'Distance to nearest: Well-"I.W f.,__ Foundation Property Line 0 w DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the Work,w'ill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i 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 1 certifies the following:"l certify that in tl4e performance of the work for which this permit is issued, I-shall.employ persons subject to workman's compensa- , tion laws of California." k °F ; The applicant must call for I requi i s tions. Complete drawing on reverse side. 42 Signed � Title: � C.L } Date ; - s FOR DEPARTMENT USE ONLY -- Application Accepted by Date / Area A! Dat 7 r ` or Grout Inspection by Date mal Inspection by Additional Comments: E r -- ❑ Stk 466-Ml O Lodi 369-36211 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CK ' RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.10/831 I� O� �- I EH 1428 �]O