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e �. iA- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Rules and Regulations of the San Joaquin Local Health District. Job Address ^lltoCity Lot Size �, PM Owner's Name O4�� O a~ Address Phone Contractor_l` o� ` Address 1 �4 WLlCense No.LS761? Phone V7 y r 7d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 5 Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack 17Tracy Type of Casing Specifications f'1 Public �' ' Fl Other w C]Delta Depth of Grout Seal Type of Grout _. 1 1 Irrigation ^ —.Approx. Depth t.1 Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ;I Depth Filler Material (Below 50'1 -- I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR IADDITION l 3 DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 4`_11Corridiercial— Other (� Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: -' Water table depth SEPTIC TANK ❑ Type/Mfg L 11 0 14a a ' '"`Capacity O No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well_—'Foundation fid- > Property Line x20,6 LEACHING LINE ❑ No. & Length of lines fG a Total length/size (� FILTER BED ❑ Distance to nearest: Well Foundation o7 O - Property Line ;2 Q F SEEPAGE PITS l I Depth _Size NUmbet SUMPS Ll Distance to nearest: Well _ _ Foundation JOQ Property Line DISPOSAL PONDS ❑ 1 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 I rules and regulations of the San Joaquin Local Health District. I 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 taws 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 appi.icant m st call for aJ required in7pec_tiogr, Complete drawing on reverse side. h ' Signed X f Title: Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date Area �f it r Grout Inspection by, Date Final inspection by Deur/� Additional Comments: '•" ❑ Stk 466-6781 r ❑ 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 I FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. i INFO �j .,EH 13-241REV.I/N51 -74'vo �Q•UC7 �/ /� 8 �.9 - EH 14-26