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APPLICATION FOR PERMIT " SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ter' _ (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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.. v! rt T w ; 4 Lot Size,�-� � PM Jab Address / City Owner's Name EIIdress Phone Ox 4P69-11061 Contractor �"'"' Address �7 CRfC �-4- License No. Phone F' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 ❑ Public ❑ Other ❑ DeltaDepth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth D'Eastern+_ Surface Seal Installed by i State Work Done ` Repair Work Done ❑ Type of Pump H.P. `,, fi Well Destruction ❑ Well Diameter Sealing Material (top.501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLA ION ❑-,REP-REP - —rDESTRUCTION-O-{No-septic system permitted if public sewer is f� y l available within 200 feet.) rleo Installation will serve: Residence— Commercial_ Other Number of living units: _,L— Number of bedrooms i f i- Water table de th A Character of soil io a`�epfli o4 3'feet:_d-g , p,. SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments f ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r T6tal length/size X LEACHING'LINE ❑ j No. & Length of lines 3 _ a— --- ..._ -—; 2 t . FILTER BED ❑l� Distance to��nearest: � Well —Foundation ` ._.� Property Line � SEEPAGE PITSDepth c2 5, Size Number I 74 �_ SUMPS . ❑ Distance to nearest: Well Foundation`47 ' - Property Line DISPOSAL PONDS ❑'- 1 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 fallowing: "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 persons subject to workman's compensa- tion Empensa- tion laws of California." J' F Theapplicant m II for required inspections. Complete•drawing-on-reverse side:- Signed Title:�T �t - Date: FOR DEPARTMENT USE ONLY _ ` ) � � i Application Accepted by d Date Area..� o Pit or Grout Inspection-by�R Date Final Inspection by fy Date Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 83541385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE CASH AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. INFO ' _ + EH 13-241REV.t/957 EH 14.28