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APPLICATION FOR PERMIT - 'Q SAN JOAQUIN LOCAL HEALTH DISTRICT v` 1601 E. HAZEL T ON AVE., STOCKTON, CA Q 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 51571 E. Q„� . -D n`^.(J-tl+ 1�. City Lot Size 100 O-KXJAO I PM Owner's Name /A Address Qo l7� 16g Phone 31 0-7 9-7 Contract Address Q C)AJ 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 ❑ 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 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 X Commercial_ Other Number of living units: I Number of kedrooms �e Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 10 Property Line S1 n^ f � � LEACHING LINE No. & Length of lines c�C " LAO (Total length/size Q �' FILTER BED El Distance to nearest: Well�— Foundation 10 Property Line _S r SEEPAGE PITS ❑ Depth LS S � Dumber SUMPS X Distance to nearest: Well 1001 Foundation 10 Property Line 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 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 m st call for alLrequired inspections. Complete drawing on reverse side. Q Signed Title: V.P.V Date: ` u FOR DEPARTMENT USE ONLY 97 Application Accepted by Date Area Pit or Grout Inspection by Date Z inal Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copes to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13.24(REV.1/e 5) EH 14-28 C� 00 /