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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 WrVAJR City Lot Size PM Owner's Name 'a. Phone Z Address -S °�"+ Tr Contractor�5, � -�+ Y_Address 3i ��` 4 License Nom?_�ZT,E�Phone —J8" TYPE OF WELL/PUMP: NEW WELL a WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P P. LINE FOUNDATION - AGRICULTURE WELL OTH f ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa��n cy Type of Casing Specifications fl Public ID Other ta Depth of Grout Seal Type of Grout I I Irrigation pro.. Depth I I Eastern Surface Seal Installed by - Repair Work Done Ll Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material Ieelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION i I (No septic system permitted if public sewer is \ / �q r available within 200 feet.) L v Installation will serve: Y'deuce Commercial Other Number of living units: Number of bedrooms Character of soil to a d th of 3 feet: p Water table depth SEPTIC TANK Type/Mfg T f Capacity_j(94_0 No. Compartments PKG. TREATMENT PLT. ❑` Method of Disposal Distance to nearest: Well ° Foundation Property Line LEACHING LINE 4❑ No. & Length of lines Total length/size FILTER BEDS ?f O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size s Number r SUMPS ❑ 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 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: "I 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 ust call for all requir ins ctions. Complete drawing on reverse side. :- ,�-- �- Signed X Title: Date: Ewe FOR DEPARTMENT USE ONLY a 2 = Irl Application Accepted by ��W� Date l—`- Sr rea� � �— Pit or Grout Inspection by Date �y Fi l Inspection by Date Additional Comments: ✓ `C ❑ 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 DATE PERMIT'NO. INFO CASH a.EH 13-24 IREV.t/n 5) r2�' EH 14-28