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i APPLICATION FOR PERMIT I � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 I 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 ! wwiri �/ u ` City Q� Lot Size PM Owner's Name Jo zi.g� if. �Q7JI Address woo/ ww;� �� '�' Phone 'dr9f'If,0'"ap Contractor C-) t Address License No. Phone E TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications { I Public ❑ Other Cl 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. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ALFiller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION Wo septic system pormated if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other \ Number of living units: i Number of bedrooms Character of soil to a depth of 3 feet: ' w," —- Water table depth s �� SEPTIC TANK ❑ Type/Mfg Capacity--.-I_D_P—j-0 No. Compartments PKG. TREATMENT PLT. ❑ `A Method of Disposal Distance to nearest: WellDf-� Foundation Property Line 149 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line i E SEEPAGE PITS i I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I v�wv 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 San Joaquin]Local Health Di$trict. 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." t The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: fI. � �.il �c• Date: ' t F DEP TMENT USE ONLY Application Accepted by date rea Pit or Grout Inspection by L Date Final Inspection by Date� f Additional Comments: ❑ 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 R CK RECEIVED BY DATE PERMIT NO. +.EH 13-24 1REV.s/HS) Eli 1428 .0 Ll