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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 Rules and Regulations of the San Joaquin Local Health District. _ Job Address � 9� City Z45 . Size PM Owner's Name Address 1�'/ - Phone Contractor/*?W12�00J" Address l � V � icense No. 36;WJ__J"1 Phone 74!ro� TYPE WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: S K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE *I TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. II Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public [ Other ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation —.-Approx. Depth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 50') Depth Filler Material IBeI w 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITIO I DESTRUCTION € I iNo septic system permitted if public sewe available within 200 feet./ Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms �(� ° �✓�r<� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity G No.Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines �/�!� dQ Total length/size % FILTER BED ❑ Distance to nearest: Well es Foundation �Q Zt Property Line d SEEPAGE PITS ICL Depth 2�� Size � « Number SUMPS D Distance to nearest: Well � foundation 7-0,74- Property Line ef'U 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 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."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 must c or all re uire spe s. Complete drawing on reverse side. Signed X Title: Data: 'Fir— FOF JDEPARTMENT USE ONLY �I Application Accepted by Date1 /' Area t or Grout Inspection by ,° 'r dale Final Inspection b � � /� � Date Additional Comments: ❑ Stk 466-6781 ❑ 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 CK 4 FEE INFO sJAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIIVNO. +. EH 14-28 EH 13-24 iREV.i i H 51 +[�W� / (/� !!!