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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDF (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. 1861 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address _ l!j 1.t1. Lot Size PM 4 Owners Name 7 Address +L�_-� ' F 7 T I Phone - Contract o cc Q Address._ '�-! �_`�- License No xaa�Phone L YPZ E OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 - OTHER ❑ DISTANCE TO NEAREST SE-PTAC TANK SEWER LINES _. DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL _— OTHER WELL PITS/SUMPS INTENDED IUSE TYPE OF WELL PROBLEM AR -CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weir x ation pecif Well Casing 71 Domestic/,Private Ci Gravel Pack ❑ Tracy Type of Casing_-- Spefications ❑ Public if ❑ Other ❑ Delta Depth of Grout Seal Y e of Grout ---Approx. Depth ❑ Eastern Surface Seal Installed by F1 Irrigatiogl LAPP P -� Repair WoF{c Done ❑ Type of Pump I H.P. -- State Work Done — 04 Weli Destruction ❑ Well Diameter ( Sealing Material (top 601 6_ ,Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ EPAI !ADDITION .11 DESTRUCTION ❑ iNo septic system permitted if public sewer is �f y available within 200 feet.) JJ 1A� Installation will serve: Residence Commercial Others- n r✓� Number of-living units,, -Number zfdrooms be Water table depth Character df soil to a depth of 3'feblr 4 - SEP+ ', r. No. Compartments TIC TANK / ❑ Type/Mfg !r Capacity PK-G. TREATMENT PLT. '❑ r.�J Method of.Disposal i_ Distance to nearest: Well ~! ,Foundation Property Line s LEACHING NE ❑ No. & Length of lines Total length/size FILTER�BED El to nearest: Well Foundation Property Line SEEPAGE PITS Depth 4<<5 Size Number f SUMPS �-- El Distance to nearest: Well_1��_— Foundation �� Property Line SUMPS PONDS'� ❑ I hereby cerhat I.have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,.and n y t rules and regulations of the San-Joaquin-Local-Health-District. Home owner orficensed 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 it.such manner as to become subject to workman's compensation laws of California-"Contractors hiring-or sub-contracting signature certifies the following:. tion 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 Cal--rforniac" The applicant mtist call for 11 r ad inspections. Complete drawing on reverse side. _ � /� A. Titre: Y Date:f�SS C� r? Signed X ` FOR D ARTMENT USE ONLY �( / Application Accepted by Date_/6 t/ Area ' (2)or Grout Inspection � Date � � Final Inspection by Data Additional Comments: 171 Stk 466 6781 [1 Lodi 36&3621 ❑ Manteca 823-7104 ❑ Tracy 835-M 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 G . EH 13-24 1REV.1!a 5; EH 14.26 �,.�