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APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 a , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) i.. 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 / City -5110 C /0Aeot Size7S S /X3''S PM Owner's Name — �'_" '��' Address Ct FV"-t— Phone � ContractoreTA ress � V "1, A6a?_icense No./ 27� Phone TYPE OF WELL:/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O 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 ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. y%State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top Depth Filler Material (Bel 50') 00 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [.If DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: 4 Number of bedrooms Character of soil to a depth of 3 feet: -Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ® No. Compartments y _ PKG. TREATMENT PLT. ❑ 6 �,, / r Method of Disposal 4/ Distance to nearest: Well! i�otr on Property Line,2 eD LEACHING LI F-) ❑ No. & Lerigth of lines / LJ j Total length/size El BED Distance to !" nearest: Well . kTdation .Property Line SEEPAGE PITS I I Depth ze_ _ Number UMP Cl Distance to nearest: Well motion 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 mu call f II re Wred inspe ions. Complete drawl on reverse side. Signed X 17 i e: Date: FOR DEPARTMENT USE ONLY p ' Application Accepted by , . � �� . Date O �A ea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I ❑ 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•95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IREV.1/8 5) / (/ /.. a s EH 14-26 [ ��`a 111 '