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�1Jc� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES IL YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby trade 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 _ZY,&J-/ //,ltt) f` C City Lot Size PM 64 An Owner's NameAddress Adr Phone ' -33 Z3 L el .1 - t - I Contractor +Address 2S �/ � ense No. 4W,?/a Phone —/! TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /per • SEWER LINES DISPOSAL FLD. 100 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation // Dia. of Well Casing Domestic/Private ,I Gravel Pack ❑ Tracy Type of Casing��. ` Specifications ('i Public ❑ Other I n Delta Depth of Grout Seal �D TypeA of� ut . I I Irrigation -Approx. Depth t I Eastern Surface Seal Installed by G[�CICl1Y_ _ 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 1:) REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is _ i available within 200 feetA Installation will serve: Residence_____ Commercial_ Other Number of living units: Number of bedrooms S Character of soil to a depth of 3 feet: Water table depth J '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 Total length/size r FILTER BED ❑ Distance Ito nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth I Size Number 1 = SUMPS L-I Distance to nearest: Well Foundation Property Line -DISPOSAL-PONDS. 0,-- 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, ander I 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 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 applic nt m st call for all require 'nspections. Complete drawingo reverse de. +p 4 i Signed X ' Title: Date: 17 FOR DEP kliENT USE ONLY ►Y M Application Accepted by Date ID Pit or Grout Inspection by Date Final Inspection by f EB 4 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-MN�A� SAG , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA�g,�1gh1RONM PERMIT ISERVICES INFOFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �y DATE PERMIT�NO.ov OD J + EH 13-24 IREV,1/R s 1 [R 7 �-�^r r 1 p{ 0 � 0� 3� J! EH 14-ZB �l