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APPLICATION FOR PERMIT SAN JOAO.UINALOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 E PERMIT EXPIRES 1 YEAR,FROM`DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin LocalHealthDistrict 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. 18652 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. LR* VCI _ Job Address '' ' �ityk' r` Lot Size PM Owner's Name - � � - Address _1��b �c2� Y'�D! � Phone Contract U Y rp Address 1u' -icense No. Phone TYPE OF,IWELL/PUMP: NEW WELL ❑ 'wWECOREPLACEMENT'❑' - DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ QN i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL. ,OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing Cl Domestic/Private p Gravel Pack ❑ Tracy Type of Casing 'f:= �. Spedifcations C1Public ElOther LlDelta Depth of Grout Seal - - Type of LGrout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal stalled by Repair Work Done ❑ Type of Pump H.P. i State Work Done ` Well Destruction ❑ Well Diameter Sealing Material [top 501 ' Depth Filler Material (Below 50') Vk,� TYPE OF'SEPTIC WORK: NEW INSTALLATION p REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Y available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ' Numberi of living units: Number of bedrooms t 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGEi PITS ❑ Depth Size =Number,N 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 1 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 an`y 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 drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY ' Application Accepted by 14� Date e—Al 185 Area Pit or Grout Inspection by Date Final Inspection by Date �S Additional',�Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant'17 I Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTEDIt CK.0 RECEIVED BY DATE 7P�ERMIT`NO. + EK 13-241REV.i/a5l 1 � .,� - �OO Y -N— OS 1`7� -- EH 14.281 66