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i 7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA NoG1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tva'Pj,•� {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. Job AddressJ S' Now e }� PM City S j'7CA) Lot Size Owner's Name 20 A'A(-S) AV,4 Ala Address S A, Phone 7� & Contractor )0:' C. L,Jcsa� _Address 7 A-1, 4DEC.,e nee' A✓E' License No. Phone_'14-r 397/ TYPE OF WELL/PUMP: NEW WELL'❑ -' WELD REPLACEMENT ❑" DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS _ ....._INTENDED.USE�,,,�.,� .TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS ❑ Industrial 4 O Open Bottom ❑ Manteca f Well Excavation Dia. of'Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type f Casing 5pe6ficatioris M Public I-) Other ❑ Delta Depth o Grout Seal Type of Grout + i I Irrigation —._Approx. Depth l I E rn Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') W �t Depth Filler Material iBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION f') REPAIR/ADDITION L.I DESTRUC N iNa eptic system permitted if public sewer is � a ilable within 200 feet./ Installation will serve: Residence Gommerciaf_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE. '❑ No. & Length--of lines Total length/size {y� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I bepth "f Size Number SUMPS ❑ Distance`to`nearest: 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 1 rules and regulations of the San Joaquin Local Health DFstrict. 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 must call for all required inspections. Complete.dra—Z71 g on reverse side. Signed Title: Date: 9D " OR-DEPARTMENT USE ONLY Application Accepted by Date Area-$;Ti I' Pit or Grout Inspection by Date Final Inspection by L�z1 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH G ..EH 13-24(REV.Fie,61 e j i/t o EH 14 26 J V