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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he(eby 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 6scity C Lot Size PM Owner's Name Address _ 2.D.S-:a kArr/_S Ti Phone Contractor r'��& Address 0AJ) License No.� D�3 `(Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE �777 ANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO TION SPECIFICATIONS ❑ Industrial LJ Open Bottom El Manteca Dia- of Well tcavaDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasiSpecifications * Public n Other F1 Delta Depth of Grout Seal f Grout _ I 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted it public sewer is 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 I � r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' ❑ Distance to nearest: Well Foundation Property Line 'v1 � SEEPAGE PITS ['I Depthx Size�� + �'� Number SUMPS Cl distance to nearest: Well Foundation.++I'04 t Property Line DISPOSAL PONDS ❑ 4s '" ", _ ' j hereby certify that I have prepared this application and14hat the work will be drina�in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distnct:f "" { 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 t orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of he rk for which this4 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu II fora rQquired ins pec omplete dra ing on reverse side. ! 1 Signed lei 1 Date: FOR DEPARTiNEfYT,USE ONLY Y Application Accepted by Date Area 1 l� Pit or Grout Inspection by Date j "Final ItItIpection by Date- Additional Comments: (ffi I ��SI7 '� LrN y ftp.5it 17M k1,T(_tq Pow) " ❑ Stk 466-6781 ❑ Lodi 369-3621 f ❑ Manteca 823-7104 ❑ TrAy 5-6385 f`<� �( f • Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St�k., CA 95201 J Y/3/i. i FEE I INFO AMOUNT DUE AMOUNT AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. +. cod EH 13-24(REV, 5) vV �� EH 14-28