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APPLICATION FOR PERMIT -Al SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (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 S Y G 1 5 V` CityT� Lot Size PM Owner's Name �!/��/ �� Address �� Phone S� ContractorAddress Z1Ze G2 /./��'� License No. .Z j Phone `— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF 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 f ! Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _..Approx; Depth l I Eastern .Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. - State Work Done r h Well Destruction ❑ Well Diameter Sealing Material-(top 501 ' 8 Lt D 'E� Depth Filler Material l8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIRIADDITION {,I DESTRUCTION I I (No septic system permitted if public sewer is R available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedroorbs E l)J Character of soil to a depth of 3 feetr �' Water table depth SEPTIC TANK ElType/Mfg ' Capacity' ' No. Compartments PKG. TREATMENT PLT. ❑ ,f - � Method of Disposal Distance to nearest:~ Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: s Well' Foundation Property Line SEEPAGE PITS I I Depth I Size Number V3 SUMPS L� Distance to nearest: Well Foundation Pro�erty„Line DISPOSAL PONDS ❑ M � '' f w i1J'J I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,"js 6 laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I cbrtify that in the performance of the w r,1k 3r?whiich1his pbfrnii'r�s"rssued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.”Cdntr ActoF A�Kinr;g a sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ ei rsdns subject to workman's compensa- tion laws of California." 1 The applicantsquire . Complete drawing on rev e Signed Title: Date: 1� Fq.R DEPARTMENT USE ONLY 9 Application Accepted by Date ��"//–�� Area LOW Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369=3621 0 Manteca 823-7104 `- i] Tracy' 835-6385 Applicant.Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;--Stk:, CA 95201 ---�-°-••.----� ---r------.,dam �- _ _;� - - --...�_ .... CK INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/n5) fiQ a EH 14-28