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_.....tom. APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 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. ` 7 /f Job Address 7 �' City F Lot Size <'C PM ! i rr '1AOwner's Name n Address 10001 G. 1 Adr0i_ .s /l� Phone .3& /' f Contract Address��9 lsiX�( � Ili I1-License NJM16 Phone/ 1 TYPE OF WELL/PUMP: NEW WELL X' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 'K SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1.V_b SEWER LINES DISPOSAL FLD.115 0 PROP. LINE I FOUNDATION / AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrialppen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications -12._- F Public n Other ❑ Delta Depth of Grout Seal c L� - nType of Grout 9_S1A 1 I I irrigation .Approx. Depth l I Eastern Surface Seal Installed by j etr} II�Qr 1�l4lCt C`�n�y1 S � Repair Work Done ❑ Type of Pump sj,,jh H.P. Z. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'I Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ('1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is r„ available within 200 feet.) 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE �" ❑ No. & Length of lines Total length/size -- FILTER BED ❑ Distance to nearest: Well Foundation Property Line 5 SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 shalhnor- employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting sigriatur 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- t. tion laws of California." The applicant.4pust &all f r all equired ' spections. Complete drawing onn reverse side. i Signed X �.i �d Title: C,.3 ,a cl Date: L' _(2 } FOR DEPARTMENT USE ONLY ��}} Application Accepted by Date v��' Area , �- Pit or ro t Inspection by ate 1�Final Inspection by Date/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 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 RECEIVED BY DATE - PERMIT'NO. EH'43-24(REV.rir<eY —_E A-26