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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address � S 6" nom��'� L, City Lot Size 21 PM Owner's Name Address 967 �clt-a ;Ss7 AaIL Phone N � Contractors Address License IVo.H7+?D66 Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.kLINE + FOUNDATION AGRICULTURE WELL OTHER WELL P1S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .� ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f„ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 k Depth t=iller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTIO (No septic system permittbd if public sewer is available within 200 feet.)` Installation will serve: Residence— Commercial— Other ! Number of living units: Number of bedrooms A Character of soil to a depth of 3 feet: Water table depth # l SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments ! PKG. TREATMENT PLT. ❑ Method of Disposal I • "'Distance to nearest: Well Foundation Property Line t n LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED a ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 0 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 r rules and regulations of the San Joaquin Local Health District. ; (J' 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 n¢ employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signatui�s��[ 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 applican must call for all re wired i ctions. Complete drawing on reverse side. k Signed Title: Date: FOR DEPA TMENT USE ONLY Application'Accepted by Date Area 1 Pit or Grout Inspection by Date Final Inspection by 64– Date o Additional Comments: ❑ Stk 466-&781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 I Applicant- Return all op` to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED # RECEIVED BY DATE PERMIT N0. INFO (� + EH 1324iREV.t/B5J 3 �°00 � S-- EN 1428