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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 � te '493 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) L.— Application .-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 62 O ;?57 ny City Lot Size PM Owner's Name 7;Cy�.I,r/7 )F�Addres7 A-P. hone �y /� �fA ,1, u7� Contractor l�.�l�-Iv"-f AddressUA4:a License No.& Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _..FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. !Z State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Jt/ Depth Filler Material (Below 501n TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION € I (No septic system permitted if public sewer is I 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 I Depth Size Number SUMPS L-i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - - 1 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 Di1trict. 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 person's subject to workman's compensa- tion laws of California." The applicant It JV all re pect(ons. Complete drawing on rover�e�side. Signed Title: 1 �j< , Date: OF R P TMENT USE ONLY Application Accepted by Date v O Area ©� Pit or Grout Inspection by Date Final Inspection by Date/ Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C7 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 CK A CASH RECEIVED BY DATE PERMIT*NO. +.EH 13-24(REV.I/H s) r EH 14-2a14/ -e a1