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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. �J JobAddress r 1�_( - ! -� �� City ELC A A) Lot Size 9 PM Owner's NameTad" Address Z 7�2 ��_ R.M J Phone Contractor's Name No. -IL560 - h-- a Phone (f TYPE OF WELL/PUMP: NEW WELL Lr WELL REPLACEMENT ❑ DESTRUCTION ❑ NA PUMP INSTALLATION II SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES '7' DISPOSAL FLD/jOC)_�f_ PROP. LINE 20 FOUNDATION .�� AGRICULTURE WELL OTHER WELL-0-0 PITS/SUMPS � - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing Domestic/Private C1 Gravel Pack i ❑ Tracy Type of Casing c5/i` lSpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ! ❑ Irrigation --Approx. De�pt`h,"N',��❑ Easterm-- Sur-------Surface Seal Installed by +Repair Work Done yType of Pump <_ P. .� H. Xa, State Work Dorie Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 Depth ' Filler Material (Below 501 ,TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:Residence_ Commercial_ -Others— Number of living units: Number of bedrooms Character of soil to a depth of 3-feet:-- - ' - -� Water table depth 1 ?SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y PKG. TREATMENT PLT. ❑ Method of Disposal , Distance to nearest: Well Foundation Property Line ILEACHING LINE ❑ No. & Length of lines 4 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation' I Property Line SEEPAGE PITS ❑ Depth Size Nd6er SUMPS ❑ Distance to nearest: Well Foundation 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 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 call for all required ins ctions. Complete drawing on reverse side. Signed r Title: _ Data: r FOR DEP TMENT USE ONLY / ,, Application Accepted by Date _ (a`�u�" Area 0 & r Pit or Grout Inspection by Date r 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO p CASH + EH 1324 RIEV.1018W 0 g� 1 3 The t 3a X338 EH 14-26