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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11,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 'T / cn City AM M#WLot Size I in-c P Owner's Name � n 0�1 Address �1'17 3 z- �C�7 z�—LN Phone v Contractor � K Address i -]&,g a/ License No.-;�05)2/ Phone 36f3 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 INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public f-1 Other E] Delta Depth of Grout Seal Type of Grout _ _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work!Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 2�\ Depth Filler MateriatlBelo 50') TYPE OF SEPTIC WORK: NEW INSTALLATION F7 REPAIR/ADDITION- DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: R�Jsidence Commercial_ Other Number of living units: 1 Number 2— Character of soil to a depth of 3 feet: LV Water table depth SEPTIC TANK Type/Mfg � ' Capacity 4 a No. Compartments .✓�\v PKG. TREATMENT PLT. ❑ [ Method of Dispgsal Distance to nearest: Well Foundation Property Line —10 LEACHING LINE No. & Length of lines Total length/size FILTER BED' ❑ Distance to nearest: WellFoundation Property Line _ SEEPAGE PITS VDepth a _Size 16 Number SUMPS ❑ Distance to nearest: Well Q_tFoundation -Afoperty-Line �S DISPOSAL PONDS ❑ I hereby certify that f have prepared,rhis 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 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 subcontracting 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 applicart ust call for all r quired inspections. Complete drawing on reverse side. SignedX Title: Wts Date: s DEPARTMENT USE ONLY Application Accepted by + Date 1 b Area ��ll �� gF1or Grout'Inspection by Date Final Inspection by w Datef, � _ DAdditional Comments: _ ❑ Stk 466-6781------- ❑ Lodi 369.3621 p Manteca 923-7104 _._.❑ Tracy 835-6385- Applicant 35-6385 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 CK SH RECEIVED BY DATE PERMIT NO. CA INFO ^/ �AS �{/� +.EH 13-241REV �y j , C /AiTV EH t�-28 es 11//