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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone 1209) 466-6781 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED T :.,(Complete in Triplicate) -to zrvv., . 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . :,4. . �. w Jab Address45203 1lK� �� City�/ ��. Size PM Owner's Name ALS 0 / V Addressg�a�••frl�� Phone Contractor's Name License No. =7 Phone �3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE: FOUNDATION AGRICULTURE WELL _ OTHER WELL PITSISUMPS 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 ❑ Tracy Type of Casing_ Specifications 0 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout (}� ❑ Irrigation --Approx. Depth ❑ Ea t rn Surface Seal Installed by �r Repair Work Done ED Type of Pump . H.P. State Work Done�� F �'�- [�I Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _Y 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. Compariments PKG. TREATMENT PLT. ❑ Method-of Disposal Distance to nearest: Well Foundation Property Line 1�g, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER-BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 parsons subject to workman's compensa- tion laws of California." The applica call for all re wired inspe tions. Complete drawing on reverse side. Signed Title: �� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date (`/ � Area -Pit or Grout Inspection by %L:::1Date Final Inspection by C � l o�ti`s?7 Date 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 5201.-'FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMITNd.. INFO +EH EH 13-24 IREV-101831 J1 s \C-1 1t? 'S