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APPLICATION FOR PERMIT _ II SAN JOAQUIN LOCAL HEALTH DISTRICT No `- 1601 E. HAZELTON AVE., STOCKTON, CA �tJ Telephone (209) 466-6781 PERMIT EXPIRES tYEAR FROM DATE ISSUED -y (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 [i City Lot Size PM �i Owner's Name ., I - Address Phone Contractor AA t T�� U—L Address 3 S a LA-) CL License No.q3olvx�Phone 9 kA TYPE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 70< FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USETYPE 01 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 O F1 Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout a _ I I Irrigation __Approrc. Depth l 1 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 18elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION L! DESTRUCTION eptic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other ' i Number of living traits -- J-Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines I Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation I Property Line SEEPAGE PITS l I Depth Size f Number SUMPS Ll 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 rules and regulations of the San Joaquin Local Health District. f t 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 becornesubject"to workman's compensation laws of California."Contractor's hiring or sub-contracting signature res 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- 3 tion la of Caliiorn' , The applic s call f r �n.aE requiid mplete drawing on verse si C ( I Signed Title: Date: rpt{. FO DEPARTMENT USE ONLY l `] Application Accepted by- 1140.4 AA `tom Date `� Area - Pit or Grout Inspection by Date Final Inspection by Date }�Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l ApplicantlReturn all copies to: Environmental lieelth_Permit/Services.1601 E. .Hazelton-Ave.,..P.O._Box.2009,.Stk.,-CA.95201-_.,.. .F! FEE AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT�NO. INFO ��p (� r EH 13-241HEV. 5JJ /r r�S, tX lux., (. EH 14-29 ✓-+ -1