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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone !2091 466-6781 PERMIT EXPIRES TYEAR 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Addres Cit , Lot Size a4fteA4gPM J r i Owner's`;Name` / a4? Address: �[f// r�� Ai i Phone Coriwc rorY / �� Address �Cl /�/ eA ,, License EV �Z-6 Phort TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w FOUNDATION AGRICULTURE WELL -.OTHER WELL --,PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' f M Public Cl Other I7.Delta Depth of Grout Seal Type of Grout _ i I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Iler Material IBelow 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR ADDITION. DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) 'V Installation will serve: Residence—mCommercial Other / Number of living units: —/LNuber of be rooms �, 1 Character of soil'to a depth of 3 feet: Water table depth _ f I 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 line 7-ta1 length/size FILTER BED ❑ Distance to nearest: Well k-�V Foundation 10 Property Line - 1 I SEEPAGE PITS f I Depth Sire Number SUMPS � Distance to nearest: Well X Foundation_ Property Line —DISPOSAL-PONDS ❑ - = • - , I hereby certify that I have prepared this application and 1hat'the work will be done in accordance with San Joaquin county ordinances, state laws, and� 1 rules and regulations of the San Joaquin Local Health D stfict. 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, l 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's compensa- tion laws of Ca fornia." The applicant t all for eq 'ed inspections. Comp`late-drawing-oni'rever e. Signed XTitle:, Date- FOR DEPARTMENT USE ONLY �j Application Ace ed by Date ` u Area Pit or Grout Inspection by Date Final Inspection by Y DateU Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 * ^ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.1/8 51 EH 14-26 �( '�"1 �.� 90-3-4o3 0' 3.4o3