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APPLICATION' FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`TON AVE., STOCKTON, CA Telephone (209) 466-6781 rg 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 l ay Lot Size PM AfodpAf Owner's Name r C—P + �rC +7 Address rl� ! '�u orf S� �� Phone Contractor afCoed— r Address lcI 6'V\Z License No.7 01/t Phan, i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES 1077 _ DISPOSAL FLD. IGra PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS WTENDED'-U$E *"TYPE'OF-WELL` PROBLEM AREA CONSTRUCTION'SPECIFICATI S I/ ❑ Industrial [D Open Bottom Manteca Dia. of Well Exc y�ti Dia. of Well Casing ^.Domestic/Private Gravel Pack ❑ Tracy Type of Casing C- Specifications ff a ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout C +2 ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.h Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms tvy Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T .- ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal !. Distance to nearest: - Well Foundation' Property Line � LEACHING LINE L1.11 No. & Length of lines _ Total length/size FILTER BED ❑ ' Distance to nearest: Well Foundation Property Line k SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ ii Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pirepared this application.and that the work will be-done in accordance with San Joaquin.county ordinances, state laws, ander rules and regulations.of the San Joaquin Local Health District. 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 I 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 m ca for all r ui 6d inspections. Complete drawing on r erre side. r ; 2 c i Signed X Title: l Dat FqRPEPARTMENT USE ONLYrn Application Accepted by � Date �� Pit or Grout Inspection by NIA Date Final Inspecti n b r --@ Oate Additional Comments ' l -Fr ' Ad /v ❑ Stk 466-6781 ❑ Lodi 369-3621 d Manteca 823M04 ❑ Tracy 635-6385Wa( Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 951 CK 4 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO.- I ! EH 14-2e + EH 13-24 IREV,7 A 5)' S