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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH. DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA II Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I'. (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 Lar City Lot Size 70 Y(12 f PM Owner's Name 0 5 1!' I i1�1,d h f�l�°V��" Address ""(P �� S � � �� Phan J 9 �g _. ._ Contractor's Name License No. - Phone .� TYPE OF WELL/PUMP: ilii ` NEW WELL ❑ .,.,' _ ,WELL REPLACEMENT-❑_._ ..,DESTRUCTION ❑ PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -_PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _� t TYPEOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottoms ❑ Manteca Dia. of Well Excavation Dia'. of Well Casing ❑ Domestic/Private ❑ Gravel Pack "❑.Tracy Type of Casing - i Specifications 1-1Public ❑ Other ❑ Delta Depth of Grout Seal - 4 Type of-Grout 91 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ( Repair Work Done ❑ Type of Pump H.P. State Work Done , a [ Well Destruction. ❑ Well Diameter Sealing Material (top 50') F{ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW'IavailableINSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is within 200 feet.) x Installation will serve: Residence— Commercial✓Other < Number of living units: —.11;Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 171Type/Mfg Capacity tNo. Compartments PKG. TREATMENT PLT. ❑ IN `�- Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ElNo).& Length of lines y:� - Total length/size -, ' FILTER BED ❑ Distance'to nearest: Well Foundation 3Property Line d r .IMS - SEEPAGE PITS ❑ Depth Size L Number F�� SUMPS 1�- Dis`tance to nearest: Well Foundation Property Line 6 DISPOSAL PONDS ❑ IE 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 workfor 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." I The applicant must call for all required i ctions. Complete drawing on reverse side. s Signed I! Title: Data: -:�- 1 I FOR DEPARTMENT USE ONLY I Application Accepted by41A - -Date - A. _ Area Pit or Grout Inspection by iM Date Final Inspection by Date Additional Comments: �N P�v ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Retum all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FE INFO' AMOUNT DUE _AMOUNT.REMITTED CKCASH RECEIVED BY DATE __ ,PERMIT`NO. «- -1777 + EH 13-24IREV.101831 (I �a '' `K`' v i EH 14-28