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5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA } Telephone 4209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED t . (Complete in Triplicate) Applicationis 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 AddressCity Lot Size 114 C" PM Owner's Name Address =�` 4�_gQAj Phone'-36-4 ✓. � �" Contractor's Name r License No. d+ a� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r - PUMP INSTALLATION ❑ SYSTEM REPAIR L1 !' OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing. ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ElOther ElDelta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern -Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. +``-ice State Work Done } Well Destruction ❑ Well Diameter Sealing MaterialAtop 501 Depth Filler Material (Below 501 i 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 Commercial_ Other �_ r Number of living units: Number of bedrooms r I Character of soil to a depth of 3 feet: 1- Water table depth �� SEPTIC TANK ,❑ Type/Mfg Ca_pacrty No. Compartments PKG''TREATMENT PLT. ❑ — Method of.Disposal I Distance to nearest: Well Foundation ,-Pfoperty Line ' LEACHING LINE LY'-No. & Length of lines 1 Total length%size F V' I FILTER BED ❑ Distance to nearest: Well 4749 Foundation ?_D ` Property Line'12 t SEEPAGE PITS ©--Depth 5�.� Size r Number r SUMPS ❑ Distance-to-nearest: WellFoundation Property Line-,_1 DISPOSAL PONDS ❑. 1 r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joagtlin county ordinances, state laws, and A rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's,signatuYe_certifies the following:.,I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject;to wdrkman's compensation laws-of California." Contractors 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 pe;sons iubject to workman's compensa tion laws of California." The applicant must call for all.required inspections. Complete drawing on reverse side. Signed _•..r..-.�...��. Title: f � �t+�- � jii � � � Date: FOR DEPARTMENT USE ONLY, .r i 1) � ! Application Accepted by T � Date Area Pi r Grout Inspection by // ' _ Date Final Inspection by Date +� Additional Comments: ❑ Stk--466.6761_❑ Lodi-3W-3621 ❑°Manteca—823-7104--❑-Tracy—835-6385��- Applicant- Return all copies to: Environmentai Health Permit/Services 1601 E. Hazelton Ave.,-P.O. Box 2009, Stk.)CA 96201 FEE INFO -AMOUNT DUE ° AMOUNT REMITTED CASH RECEIVED BY Q DATE,' PERMIT"NO. +EH 1324(REV.10!831 ! OQ G EH 14-28 rrr - .