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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� (complete in Triplicate) Apcation'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 l0ealth District. Job irk C 1! Lot Size PM Owner' Nm� ` Address Phone Con ac r d6r�as e-0 Anse [ 2 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION b' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑� �Industrial ID Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing Lomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of 9rout Seal Type of Grout ❑ irrigation ---Approx. D t ❑ astern .Surfact eal Installed by Repair Work Done ❑ Type of Pump� h� H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF YSEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is v 4 available within 200 feet.) h Installation will serve:" Residence_ Commercial_ Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. ❑ Method of Disposal i. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number i.. j SUMPS ❑ Distance to nearest: Well Foundation Property Line f 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 1 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 Jallu as to bec a subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies4fowing: "I cet ithe ormance of the work for which t ' permit is issued,I shall employ persons subject to workman's compensate tion lawrnia.The appt call fori ed ins ctions. Complete drawing on er side. Signed Title: Date. l FO EPARTMENT USE ONLY ! On �v,.� � V� D l Application Accepted by i Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE l INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PIERMIT'NO. + FH 13-24(REV.iie5) UA _ EH 14-25