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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT yI u 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AaIJ`G (Complete in Triplicate) R I 4 HI�,V"-t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the or h9�rf D�Il�tfdmbaWK/"ft application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and• egulations of the San Joaquin Local Health District. Job Address —.J�e7^ 9t — City Lot Size PM Owner's Name A ` Address,�� di(. �- �1��^+- Phone ^ E� Contractor�"7�� -� Address 01! kicense No.4/s�2111' Phone Q-39-419M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR it- 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 4t Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump. 4.sA - H.P. State Work Done \ Well Destruction ❑ Well Diameter Sealing Material (top 501) " Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No sep is system permitted if public sewer is M available within 200 feet.) Installation will serve: Residence_ Commercial_ Other &VIL �r Number of living units: Number of bedrooms LJ Character of soil to a depth of 3 feet: Water nEC11 V E D SEPTIC TANK ❑ Type/Mfg Capacity No. Compartr PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property LEb+VIR®NM ENTAL HEAL LEACHING LINE ❑ No. & Length of lines Total length/size PERM IT/S-ERVICES FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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, 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: "1 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 must call f all required inspections. Complete drawing on(7 ":�f_eryide. Signed X4 Title: --� '�' 1' L Date: f2� F R DEPARTMENT USE ONLY 91 Application Accepted by Date /t1le- Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 CASH RECEIVED BY DATE PERMIT No. + EH1 3-24(REV.t/e5) 9tj �� 1 l O ��,.�D EH 14-28 1�O