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y 1 APPLICATION FOR (PERMIT ► 1 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 L44.5 City „L" Lot Size 2i-y'24)0 PM a Owner's Name.,-� 'if<'/10e� s�.E'!lfl6�i a Add ess� ----- F_ Phone Contractor's Name 4eld`131' 2?�' rE 'VX License No. Phone 76 0 TYPE OF WELL/PUMP: 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 p INTENDED'USE TYPE OF WELL PROBLEM AREA...,,.CONSTRUCTION SPECIFICATIONS. EJ industrial ' '❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel'Pack ❑ Tracy f Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done � Well Destruction ❑ Well Diameter Sealing Material (top 501 s' Depth "e Filler Material (Belo ') - - -• f J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ -REPAIR/ADDITION DESTRUCTION ❑ (Nb'septic system permitted if public sewer is ' available within 200 feet.) _ Installation will serve: Residence� Commercial— Other. Number of living units: / Number of bedrooms :9 { 1 Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK Type/Mfg 4� 9!.'41-rbc Capacity 1264) No.rCompartments N PKG. TREATMENT PLT. ❑ F ...s Method of Disposal Distance to nearest: Well O@ Foundation Z! Property Line LEACHING LINE No. & Length df lines Total length/size X- 3:f FILTER BED Distance to nearest: Well Foundation .2. Property Line __ SEEPAGE PITS ❑ Depth Size ;Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. f 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 r 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 applica call for all required inspections Complete drawing on rever-' sid e, Signed Title: f Date: FOR EPARTMENT USE ONLY r f Application Accepted by Data Area__ t Pit or Grout Inspection by Date Final Inspection by Date W D f� 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 1 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO., INFO CASH EH 13-24 + EW 1126{REV.101831 45