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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.. HAZEL—i 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. A I Job Address Ii City �e PM Owner's Name Address 2-77o), UPhone '****�IL—Contractor L 1M Address �� qi7—License No. (6 Z 313 Phone bv— 6 TYPE OF WELL/PUMP: N . WELL ❑ WELL REPLACEMENT ❑/ DESTRUCTION ❑ PUMP INSTALLATION El 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 ❑ ar�dustrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing tDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �_-4pprox. Depth 11Eastern Surface Seal Installed by yl } Repair Work Done Type of Pump u H.P. I 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.) v V Installation will serve: Residence_ Commercial_ Other Number of living units: Number-of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ; Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Faundation Property Line_ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to,nearest: Well--;,----Foundation Property Line SEEPAGE PITS ❑ Depth r' Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 San Joaquin Local`Health District. Homeowner or ' rise age '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 rson in such ma ner as to become subject orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t following:"I cert hat in the or anc f e w rk for which this permit is issued,I shall employ persons subject to workman's compensa tion law of California." The ap licant u f all r r drawing on a ida. ) p /� Signed Title: - ✓ to Fe f 7e fLr� Date: !— FOR D P RTMENT USE ONLY Application Accepted b (40W W4010t� Date_ Area Pit or Grout Inspection y Dae Final Inspection b DateYC7--JC � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH1124(REV.1/ss) �Sa ©c9 i �3` '�7�9 EH 14-28 7