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I APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED eQa- f (Complete in Triplicate) II pplication 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 Locai Health District. 1 lob Address iCJ - �s► �© City Lot Size PM 1 Owner's Name„I'Ya 1 r&Lya,,C I/e,Qac fr Address — ea Phone xConIractor///Q-G/La,- �w e - Addrcss,2_.Y7 091, License No22d S!) Phone C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Ih -” PUMP INSTALLATION ❑ SYSTEM REPAIR r OTHER ❑ ((DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE u 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 .0 Tracy Type of Casing Specifications iI'1 Public ! ❑ Other_ ' `'"`." - +❑-Delta,% Depth of Grout Seal Type of Grout If I Irrigation —.-Approx. Depth l 1�Eastern Su ce Seal Installed by _ Repair Work Done Type of Pump., H.P. 6 State Work Done We11 Destruction ❑ Well-Diameter ' .Sealing Material (top"50'). IIX Depth w R Filler Material (Below 50') (TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 2DO 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 T, I PKG. TREATMENT PLT. ❑ Method of Disposal [� Distance to nearest: Well Foundation Property Line ) EACHINGLINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0 �J iSEEPAGE PITS l I Depth Size T Number 'h SUMPS Ll 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 Sam 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, l 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, l shall employ persons subject to workman's compensa- "iion laws of California." •I. , 011 The applicant m t call for all required ' pectio Com lets drawing on reverse side. (Signed X Title: -��s I Date: /x- ,I FOR DEPARTMENT USE ONLY / IApplication Accepted by Date f " f -7 Area �`/{ it or Grout Inspection by 1 Date Final Inspection by Date�� I Additional Comments: ) 0 h'St; "466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 V�1 IFEEO "AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �DATE (PPERMIT NO. 1..24 H 124 I