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S, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y„ 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address ! *-u City t Lot Size PM Owner's Name I f Address Fr-e_,.0 Phone 3 SVGS 14 s e a Com„ C 7 (.#c) Contracto 4ewee glAddresst$� `7n��-#L r/�IS License No.` _gq3( Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �r—&O A DISTANCE TO NEAREST: SEPTIC TANK IJ LA SEWER LINES IVr-1 DISPOSAL FLD. PROP. LINES�� Sc 4-c FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Wel( Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public (-1 Other Cl Delta Depth-efm i ;�_ 10 Type of Grout _ 1 1 Irrigation- —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 501 ! }I Depth Filler Material (Below 50') j \ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I t INo septic system permitted if public sewer is available within 200 feet.) ; i Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 fuel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal . . Distance to nearest: Well .Foundation Property.Line I' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line s ' SEEPAGE PITS l I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line i 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, ane rules and regulations of the San Joaquin Local Health Di"strict. 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature r certifies the following- "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensi tion laws of Califor The applicant call for all requi in ctions. Complete drawing on reverse side. Signed X Title:�r�� `s� Date: e--'FOR DEPARTMENT USE ONLY Application Accepted by �`v`�` ac. Date Area Pit or Grout Inspection by Date j. Final((inspection by // Dat/e] Additional Comments: p��' 4. �Z ��a-le• l^ c�vA�nr1,, C�.Ta..;via�b� �tQlw 4I( ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 1REV.r/n 5) EH 14.28 "� S