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a Owl 4.1 APPLICATION FOR PERMIT { SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This 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. ' {I 0t-c- Lot Size 7� � � U PM Job Address Ae Phone d 71 7- 1 Contractorsdress /�3G 3rr� G irensa Nn. P6nne Contractor's Name 1/ G It License No. TYPE OF'WELL/PUMP: - NEW WELL f WELL REPLACEMENT DESTRUCTION -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ H- OTHER El DISTANCE TO NEAREST: SEPTIC TANK, 3V SEWER LINES 0 DISPOSAL FLD.�U�' PROP. LINE�� lh{ I - FOUNDATION O t- AGRICULTURE WELL OTHER WELL PITS/SUMPS U, INTENDED USE r: /:TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing l ❑ Industrial ❑ Open Bottom ❑ Manteca r Dia. of Well Excavatn Type of Casing Specifications f '" J7omestic/Private D.Gravel Pack ❑ Tracy Type of Grout CBe " ❑ Public 4 ,❑ Other. ' ❑ Delta f Depth of Grout Seat U yP ,k p w Pl I. ❑ Irrigation '-----Approx. Doth ❑ Eastern Surface Seal Installed by (�- fe 7� H.P. tate Work Done [7 -Repair Work Done ❑ d Type of"Pump J - L, C.y i"-e h t .i "Well Destruction: r K"; Well Diameter Sealing Material (top 50'1 "± Depth Filler Material {Below 50'} �le 4 ry Sd kcl0 r a - TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ septic system 200 feet.) if public sewer is j Installation will serve: r Residence Commercial_ Other t Number of living units: � Number of bedrooms rWater table depth Y Character of soil to a depth of 3 feet: '7-1Type/Mfg Capacity No. Compartments SEPTIC TANK " t Method of Disposal PKG. TREATMENT PLT. ❑ { Distance to nearest: Well Foundation Property Line ' LEACHING LINE . ❑ No. & Length of lines Total length/size t .�..� FILTER BED D Distance to nearest: Well Foundation Property Line It SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature l 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." I The applicant must call for all required inspections. Complete drawing on reverse side. ` 7 Signed Title: Date: �— I FOR DEPARTMENT USE ONLY (� Date — 7 Area r Application Accepted by Pit or Grout Inspection by ,CJI _ �Date Final Inspection by Date Additional Comments: El 5tk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental Health FEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DU AMOUNT REMITTED CASH � � +EH 13.24{REV.10183) 4 EH 14-26