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h i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZELTON AVE., STOCKTON, CA 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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .2 7 g-7 ' � �f City Lot Size PM Owner's Name -Address `oZQ / �S .' /' L.9SA'/yi.� Phone 6y9--Z�j4f Contractor Address 3S a - rise No. �q�A/3 Phone — TYPE OF WELL/PUMP: V 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ,�.. ❑ Industrial ❑ Open Bottom._ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private I X Gravel Pack ❑ Tracy, i Type of Casing AV i Specifications ❑ Public LlOther ❑ Delta Depth of Grout Seal '5 I I� Type of Gro Z_ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ElType of Pump' H.P. State Work Done Well Destruction Cl' Well Diameter Sealing Material Itop 50') 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—i Commercial— Other Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Ij PKG. TREATMENT PLT r❑ Method of Disposal Distance to nearest: Well Foundation Property Line M LEACHING LINE ❑, No. & Length of lines Total length/size k FILTER BED ❑' Distanceto&nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I _ :•� . I hereby certify that I have l repated this applicafiori-arid that the wark"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 applic t m st call for all re uireA7p ctio S. Complete drawing o e ide.17 p =i Signed Title: Date: FMI DEPARTMENT USE ONLY Application Accepted by Date "'5�� Area ' –Q` �J A s« l Pit or Grout Inspection by to �� " Final Inspection by fV j4 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 55201 FEE- INFO AMOUNT DUE AMOUNT REMITTED C7MK H RECEIVED BY DATE PERMIT`NO. + EH 13.24IREV.1/05) l� Y. s�� EH 14-28 1