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APPLICATION FOR PERMIT gq� C7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :I (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 Q City 5T&Z Lot Size PM Owner`s Name r.7� Aned_L1t� Address S? IL kTLE� one-"~ Contractor /�CPZjW Address 4 ��'00 License Nogige �/Phan 'i �rnfo e[ TYPE OF WELL/PUMP:- --i -- •NEW.WELL- ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL ! OTHER WELL PITS/SUMPS d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,� Fl•-� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation —II.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done - f ` Well Destruction ❑ Well Diameter Sealing Material {tap 501 Depth Filler I !Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION {'I REPAIR ADDITIO l I DESTRUCTION l I (No septic system pefmitted if public sewer is �! available within 200 feet.) O I , Installation will serve: Resid nce_ Commercial_ Other /.� Q�J} /�q0O r 1 ASI D Number of living units: Number of bedrooms /y fi�!/+NW yh Character of soil to a depth of 3 feet: Water table dpth SEPTIC TANK ❑ Type/Mfg ,FY Capacity _-No. Conrpartments _ PKG. TREATMENT PLT. ❑ I� rr �,. Method of Disposal Distance to nearest: Well Foundation Property Line :i .I LEACHING CINE No. & Length of lines Total length/size FILTER,BED ❑ Distance to nearest: Well Foundation�L0 Property Line SEEPAGE PITSf Depth Size Number SUMPS• Ll Distance to nearest: Well Foundation_.d o Property Line— DISP05AL PONDS ❑ ' '-1 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. ' 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 r 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 compansa- tion laws of Calif nia." I� 1 i The applicant t call for II required i spections. C m ete drawing on averse side. . Signed II Title: l Date: 'ENT USE ONLY r Ap !(cation Accepted by ,p Date Area q Pit Grout Inspection by ate -�7J✓ Final Inspection by Date Jk Additional Comments: ❑ Stk 466-6781 ❑ Lodi;ir-369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r'• Applicant-- Return all copies tojj-Environmental.Health-Permit/Services 1601 E. Hazelton Ave.,.P.O. Box 2009, Stk., CA 95201 CK INEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 13-24(REV. EH 14-28 li'