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t M APPLICATION FOR PERMIT 'i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'f (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. ', �• /�� City dG Lot Size PM Job Address _r L G QOM Address _ Phone Owner's Name Contractor / L"��JJ''1A dress -3,663 0"r/J 6C �License No �"rho � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl /??�✓� PUMP INSTALLATION 7 SYSTEM REPAIR ❑ OTHER�y 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 ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx, Depth l I Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 { T OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION I I (No septilable c systthinem rented if public sewer is r Installation will s Residence_ Commercial Other Number of living units: mber of bedrooms Character of soil 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 Foundatio Property Line th/siz LEACHING LINE ❑ No. & Length of lines Total len g FILTER BED ❑ Distance to nearest: Well Foundation Property Line �I SEEPAGE PITS I I Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 1_hereby.certify.•that-l-have-prepared-this-application-arid-that'W6 woek will be done m 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 far 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 ust call for all raq Oled instions. Complete drawing on reverse side. Signed Title: ata: FOR PEPWRTM T SE ONLY Application Accepted by Date 9/5 rea Pit or Grout Inspection by Data Final Inspection by Data k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. I INFO , +.EH 13-24 MEV.119 51 r(# EH 14-2e