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APPLICATION FOR PERMIT . : SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephbrle (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. Job Address City Lot Size Ply Owner's Name , Qr_, ,rj Pltone a q Contractor L Address r License No.c l l-a S--% Phone t.z Z TYPE OF WELL/PUMP: 74Ew WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION _ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK 4_0:29"'�S SEWER LINES — DISPOSAL W- f PROP. LINE (L f FOUNDATION AGRICULTURE WELL OTHER WELL� � PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �1 t ❑ Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation / l Dia. of Well Casing Y+Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' ❑ Public Cl Other V 1 Delta Depth of Grout Sea] Typf Grout e l I ] Irrigation -:-Approx. Depth ! I Eastern Surface Seal Installed by_U��/{�" � Repair Work Done IDType of Pump H H.P. . State Work Done. 'Well Destruction ❑ Well Diameter Sealing Material (top 50'1 t 1 Depth +^ •- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION L.] REPAIR/ADDITION f I DESTRUCTION I I:(No septic system permitted if public sewer is 1 available within 200 feet.I r Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms t F 'Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ a'' Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines / Tota€ length/size FILTER ABED ❑ Distance to nearest: Well Foundation Property-Line SEEPAGE PITS i I Depth Size —�"" _ Numb., SUMPS ❑ Distance to nearest: Well _ ' �„ Foundation x - ^"Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dt%trict. ,A ' 11, - 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, €shall net 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: "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." \ k The applicant mus call for all required inspections_Complete drawing on reverse side. � Signed X Title: Date: zPA As FOR DEPARTMENT USE ONLY Application Accepted bAby Date x�1 `-' Area Pit or Grout Inspection D to _ inal Inspection by Date�e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca r 3-7104 ❑ Tracy 835-6385 Applicant- Return all copes to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT R ITTED CK RECEIVED BY DATE PERMIT'NO, INFO CASH I +.EH13-24[REV.t i K 5) EH 74-28 1739