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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 (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.e � /J/?J10y / L _._ � � City /t',B�UlrbcyA Lot Size c�l(y `A Job Address h 2- 3 S PM Owner's Name iCRAvk 1WA c' 'A PO Address o5�°®C - 7 �3 " 4!85-4 ��"'U Phone Contractor's Name v2 License Ifo. -- Phone 3 t TYPE OF WELL/PUMP: NEW WELL ❑ :WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta _,Depth of Grout.Seal,. Type of Grout ❑ Irrigation _-A00rox. Depth ❑ Eastern Surface Seal Installed by µRepair Work Done ❑ Type of Pump H.P. ? State Work Done Well Destruction ❑ Well Diameter Sealing Material...ltop.50'1 Depth Filler Material (Below 501. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No'septic system!permitted if public sewer is f available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms !, Character of soil to a depth of 3 feet: SA,tiDy .1.x»4 _ Wator f0le dei`ti - `Y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest:' Well Foundation Property Line i LEACHING LINE ❑ ,Vo. & Length of fines Total length/size a� 16' FILTER BED IX Distance to nearest;: Well -7 Foundation— Property Line. SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS,'',❑ i hereby certify that I have prepared this'application,and the#,#he work-will 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 certifies the following; "bcertify 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 drawing on'reversd-side. Signed ��C fvLLG� Title: Date: FOR DEPARTMENT..,USE ONLY v` � I Application Accepted by -Date f --Area , T' Pit or Grout Inspection by A11A ' Date l final Irjspection by'y Date i� Additional Comments: +? ❑ Stk 466-6761 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health'Permit/Services 1601 e"He-ekon Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK' RECEIVED BY DATE PERMIT NO. _ INFO CASH:' _....e.,.e«_..� .,.. + EH 1324(REV.10183) ' EH 14-26 111 C->