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APPLICATION FOR PERMIT - {� SAN JOAQUIN LOCAL HEALTH DISTRICT j`�"`� 1601 E. HAZEL T ON AVE., STOCKTON, CA ►h� 'tt, 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 1 ,1 ST City 57ZZ2� Lot Size: 5 PM Owner's Name .y�i iY/6 ,�/9,�iK/�r/5 Address 4-, 3 G/G ,15 Phone Cgntractor .S�GF Address �//-�/cif/ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAfR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WCL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL AREA C0 STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantec Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Easter rface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter aling Material (t 50'1 Depth Filler Material (Below 50;1_ rte!} TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l 1 DESTRUCTIO (No septic system permitted if public sewer is "'\� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ]� Character of sail 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] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will he 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 must cAfor all required inspections. Comptete drawing on reverse side. Signed X�JV .�C/ITiYLt.Q ? 7��l sc.a� Title: K2W1F: 11e 1e Date: G-�� -7 FOR DEPARTMENT USE ONLY Application Accepted by Date Area J Pit or Grout Inspectio / Date Final Inspection bbyyj� Date �y Additional Comments: �-ef' �+.-S ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE t+ PERM17'NO. + EH 13-24(REV.rin51 EH 14-26