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APPLICATION FOR PERMIT „ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 Ldcal Health District. fC Job Address �2 �, 5.9•vZ)ek A' City 0?7e tot Size �^� PM Owner's Name M Ai Address Phone Contractor_ 4.121_jULG,& _ Address PAd 10V 7Czr License No.o4✓� —X—Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t 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 C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications y ❑ Public ❑ Other - -❑ Delta 'Depth of Grout Seale ^Type of Grout 1_ .x ❑ Irrigation ---approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j Y available within 200 feet) o,Installation will serve: Residence�* Commercial. Other', Number of living units: ` Number of bEdroams 1? Character of soil to a depth of 3 feet: SAN Dy A,0 Waler tablWepth SEPTIC TANK -'E D Tyne/Mfg 4-41Capacity . No. Compartments PKC. TREATMENT PLT. ❑ , , . FT- Method ofDisposal ' Distance to nearest: Well t' - Foundation Pro8rt 6n,e �� LEACHING LINE No:& Length of lines Total length/size oC FILTER BED 11Distance to nearest: Well Foundation ` ? ''Property Line w_ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: We1f. 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 Jouin county ordinances, state laws, and rules and regulations of the San Joaquin,Ldcal HealttLDi,Strjct_ , Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the worklor 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 employVersons subject to workman's compensa- tion laws of California." The applicant must call for all equired i spections. Complete drawing on reverse si'de.:.; Signed X �`a./ Title: ' �"w- o _ Date: �! FOR DEPARTMENT USE ONLY Application Accepted by iC Y Date Area_.,.. _ Pit or Grout Inspection by Date Final Inspection by Date 4-7 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 ""C SH CK RECEMED BY' `" -Cr�AT,E PERMIT ND. +�+ EH 13-24(REv.4/A5) EH 14-28 / /