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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ! PERMIT EXPIRES TYEAR FROM DATE ISSUED ! iCamplete 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 Address 14-0 � ' SO -Vtk NyyQ _�l�� ` City 4k. Ck 4"'Lot Size��S odo�p F p(� Lkoo. So _L�}� Z�_ C1. 1y" is Owner's Name `' Address L hone 1-A— 6 ex 13003 �5 M lk Contractor , `C�� + ddress )ALkCZ *V1Q101-- License No.� ___Phone .SSa TYP€ OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing m ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications fl Public (=1 Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation ___-..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump .._--_ H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501 Depths 3� ^� Filler Material (Below 501 TYPE OF SEPTIC RK: NEW INSTALLATION la REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re ' ence_' Commercial_ Other Number of living units; umber of bedrooms _ Character of soil to a depth of 3 fe - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ i Method of Disposal Distance to nearest: 11 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well undation Property Line a ' F k SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signattire 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'sicompensa- tion laws of California." The applicant sl call for all r luired i pact' ns. Complete drawing on reverse side. Signed X Title: U��_r Z - Date: l FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by /61" Date Final Inspection by Date r Additional Comments: O Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 x FEE AMOUNT DUE j AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH 1324IREV.i/wt7 EH 14-28 4,-. ��"�