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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (249) 466-67$101 J6 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4**WO4 (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 7C tJ 7 J 1 Job Address LSV � !.,_. City/o C' / Lot Size C� 11f4f'Ff=s PM Owner's Name T_'IL nES RIZ / / ►t{� Address f / r J �� 1,6 J1 Phone-334 0423 Contractor's Name ` -l7 License No. / Phone V-A3`i 6/3 r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION + SYSTEM REPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK �r6 SEWER LINES DISPOSAL FLD._c__:.1.. PROP. LINE FOUNDATION T ` AGRICULTURE= WELL �s OTHER WELL PITS/SUMPS n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a'r Dia. of Well Casing Domestic/Private :< Gravel Pack ❑ Tracy Type T g VC, p �las5 lie of Casing r Specifications ! ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout,,ijQa It i ElIrrigation FS161-42eL�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 9V& H,P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ? TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l i Installation will serve: Residence_ Commercial Other t 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 s� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number k SUMPS ❑ Distance to nearest; Well; Foundation Property Line _ l 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. 1 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 1 certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject tpyvorkman'svompensa___1, tion laws of California." The applicant m st calf for ail required ins ctions. Complete drawing on reverse ide. ! rn• C I Signed Title: �`3,Y .Y Date: c�� FOR DEPARTMENT USE ONLY � Application Accepted by -�� DateI li4rea `�]f Pit or Grout Inspection by Date r� 7 Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMl7"N Ilkr INFO CASH _ D I + EH 1426(REV,10163) —O