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V APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) £f71Vjl�.�c� NEo� p Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc 1 atlE"�aQqQba11�111 is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the`Rad Joaquin Local Health District. Job Address �� _AF_ Z,Ln UA 9 City Lot Size PM Owner's Name 1 c z Address I tJ�J P ��T Phoneffed Contractor Address License No.2.1' 6/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REP R, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK= 12SEWER LINES �Qt7,ll DISPOSAL FLD/110i— PROP. LINE.� FOUNDATION AGRICULTURE WELL�VaZZ_ OTHER WELD PITS/SUMl INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r 15t pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other FI Delta Depth of Grout Seal Type of Grout i I I Irrigation 3.(Q APP10x. Depth I I,Eastern Surface Seal Installed by - o Repair Work Done ,24 Type of Pump H.P. State Work Done � �>} Well Destruction O Well Diameter Sealing Material (top 501 Depth �l[LFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll 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 rules and regulations of the San Joaquin Local Health District. Home owner o,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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foil owin "I rtify 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 Calffor a." The applicant in r all r spections. Complete drawing on reverse sidgllf. � Signed Title: Date: /,2//1,4 ' FOR DEPARTMENT USE NLY Application Accepted by i Date Pit or Grout Inspecti y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24(REV.rix sr EH 1+20 — ��S