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APPLICATION FOR PERMIT 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 apermit 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 ALJ' S. 4-P uA is City V'Q kdg 6-/Lot Size. PM Owner's Name hp. e, � Address 4,611A Dphone Contractor's Name ' License No. �7 [�z�i Phone TYPE OF WELL/PUMP: UNIW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ t• PUMP INSTALLATION ❑ SY/�E REPAIR ❑ O ❑ DISTANCE TO NEAREST: SEPTIC TANK�jc — SEWER LINES DISPOSAL FL��O PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p ❑ Industrial �❑��OOpen Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing �omestic/Private IP/Gravel Pack ❑ Tracy Type of Casing Specifications " ❑ Public ❑ Other ❑ Delta Depth of Grout Seal `S l:' 2 , Type o"Trout �TLr1'GC ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by A Repair Work Done ❑ Type of Pump H.P. - State Work Done Well Destruction ❑ Well Diameter .� � Sealing Material (top 501 Depth - c"-� Filler Material (Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2DO feet.) r 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 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line L LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well - Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ c I hereby certify that I have prepared thisapplication 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 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 appli nt j ust call for,all requir inspections. C mplate drawin on rev r e s'de. Signed 1✓JC Title: -k /' Date: 4�7 '/ p ' i`^ r" FOR DEP TME USE ONLY I Application Accepted by ,,(L/- (� Date tF 1 /A/ (� A � Area. r Pit or Grout Inspection by � �y,a Oate 9-DLALI Final Inspection by Date Additional Comments: ❑ SIR 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 INFO AMOUNT DUE AMOUNT REMITTED CAB RECEIVED BY DATE PEflMITNO. EH 1124(HEV. 10/W) EH 1426 3 . ('>c` - 1._S. ('1!'. I1-1 �i q --1— r�� _ �r�♦ V 1• , .-.