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APPLICATION FOR PERMIT i ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 anWor 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 Joaqu n Local Health District. Job Address 'r 5;ed�� e`4,V t G� - City �'`fid t Lot Size PM goo e �L� ►�+r�. Ownef's Name O Q ► Address ff �` f r / Contractor r [;.�✓ dY!.�Yr b�-, Address Vt5 Ayrt o1 No. _ Phone LYLS S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 CS Domestic/Private . ❑ Gravel Pack ❑ Tracy Type of Casing P VC, Specifications. $e Auw-_ /`/ ��0rl'fLr6pOtbeer ❑ Delta Depth of Grout Seal Type of Grout ❑ Ifrigatioffs �'_:;�4pprox. Depth ❑ Eastern Surface Seai #nstalled by .?-y41aew Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: 'Well f=oundation Property One LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS ❑ Depth Sae Number _ SUMPS ❑ Distance to nearest: Well foundation•1 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. 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 subjectio workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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 applicant t call for all required inspecji ns. Complete drawing on reverse side. Signed X Title: Date: 3 dd Z s ,� /✓/��y FOR DEPARTMENT USE ONLY y/` Application Accepted by _>Lf�G Date ✓/t�� Are Pit or Grout Inspection by ate Final Inspection by Datea Additional Comore i] 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 95201 FEE AMOUNT DUE AMOUNT REMITTEDC� RECEIVED BY DATE PERMIT"NO. INFO EN 1324 iHEV155)155) 3 C.,u �_ - 5/ c� F-li 1 4.76