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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTR GT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C(opy ) (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 uylz—T7 PM � � City Lot Size Owner's Name 0/,7 J� - Address Phone j /� 7� Conlracto i+C S (�PiE� AddressvZ_ ��, /+'►G/` r6.2 Jyve U License No. 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 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 f`l Public H Other 1-1 Delta Depth of Grout Seal Type of Grout 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 (top 50'1 (� Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i"I REPAIRIADDITION DESTRUCTION I I (No septic system permitted if public sewer is V Installation will serve: Residence— Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms �- Character of soil to a depth of 3 feet: Watertable depth SEPTIC TANK ff—. Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE &Z No. & Length of lines Total length/size V FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t 1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line P 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, statelaws, 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 !7 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 parsons subject to workman's compensa tion laws of California." The applicant mu call for all required ins s. Complete drawing on r verse side. Signed Title: Dater ♦ FORTMENT USE ONLY Application Accepted by -' _. - 2--- Date Area Pit or Grout Inspection by Date Final Inspection b er' y' Dat S " ' Additional Comments: ❑ Stk 466-6761 ❑ 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 REMITTED INFO' CASH RECEIVED 9Y DATE PERMIT NO. s + EH13-241REY-I/Ksl EH 14-26 I F