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u APPLICATION FOR PERMIT L./ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. ` L,� L /fit/ y13.oa Job Address x/23 S' F/'CS At p City 15- CIk�_ +l Lot Size 7/-�7X Q/ PM 2 18 `J 4410 Phone /` Z y' Owner's Name i c eit�ct.- T 9�er1n/ Address I S;(f? _s SliC/�Us+tn�o Com_ q5 -A-2 Contract Address License No. Phone TYPE OF WELL/PUMP: N,3 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �. 1"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ �1 I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by _. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 ` Depth Filler Material (Below 501 TYPE OF SEPTIC WOflK: W INSTALLATION (I REPAIR/ADDITION I I DESTRUCTION (No septim c system permitted if public sewer is available within m feet) y Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms kq�ti 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 Q. Distance to nearest: Well Foundation Property Line a. LEACHING LINE ❑ No, & Length of lines Total length/size r1._ FILTER BED ❑ DYstance to nearest: Well Foundation Property Line ` SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 r rules and regulations of the San Joaquin Local Health D3trict. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica t must call for al,rreq�ui-reedd inspections. Complete drawing on reverse side. Signed'X "' ` ` �'� `' Title: 11 — Date: FOR PARTMENT U E ONLY p 1 Application Accepted by O�tle�._ Date ` Area 1--� A Date Z�1j'J'( _ ` Pit or Grout Inspection by _ � Date /1- A--�! Final'Inspection by g,44 4UW&4-e�l Data 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 95201 - r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO r �y/ �.EH 13.24(REV.r/x 5l