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APPLICATION FOR PERMIT 4 4-10 b � vi SAN JOAQUIN LOCAL HEALTH DISTR s-4 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDr` /t-- �T j (Complete in Triplicate) 13 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 SS9 e-z W4„`TWIA city 7,0G/C':6 t Size � X //,� PM Owner's NameZ C M 6J!l L 6/9 C—CA ddress 2 5//G T'J/_=ASA Ai �_ Phone 5 8 i Contractor C, Address 4 License No. 0411.u6 2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 ._ 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial p Open Bottom ❑ Manteca Dia. ofWell Excavation Dia. of Well Casing F1 Domestic/Private. -L] Gravel Pack © Tracy Type of Casing Specifications f 1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ti I 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') E Depth Filler Material (gelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is f 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 c Capacity No. Compartments PKG. TREATMENT PLT. ❑ � r 1 f Method of Disposal Distance to nearest: Well Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LlDistance to nearest: Well Foundation Property Line SEEPAGE PITS I'I Depth t Size { Number. �E SUMPS ❑ Distance to!nearest: Wel! Foundation Property Line DISPOSAL PONDS El 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. r 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: 1 certify 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 California." The applicant m call for all require inspections. Complete drawing on reverse side. Signed l � _ Title: Date: 1/,/Z-111?7-- ' I. 4 FOR DEPARTMENT USE ONLY i Application Accepted by Date Z Area Pit or Grout Inspect by a Date Final Inspection byDate 0` ' Additional Comments: OYG GeE1 . ❑ Stk 466-6781 ❑ Lodi 9 369-3611 ❑ Manteca 823-7104 ❑ Tracy 335-6385 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 C RECEIVED BY4 DATE PERMIT ND. ; INFO Q EN { EH 14-24(REV.1 i K 51 - AV �7-3