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l APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT L� 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 Local Health District. Job Address ! �/�� City Lot Size PM Owner's Name L l-f L 6 Address `� N �/ Phone DC Contractor.. 1 Address '7iD License No. 1_605 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP�TANKL�_ ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO : SEPTISEWER LINES DISPOSAL FLD. PROP. LINE FOU AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of a ion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other ❑ Delta Depth of Grout Seal f Grout _ I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by H 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 I I REPAIR/ADDITION l 1 DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of,Disposal ' Distance to nearest: Well Foundation } # r�Property Line *I..� LEACHING LINE ❑ No. & Length of lines '?W Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L7 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, 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mus for all a ired inspections. Complete awing on reverse side. �] Signed X Title: _ — _ Date: y l —S- FO SFpR pE ARTMEN USE ONLY /) Application Accepted by Data Area v g Pit or Grout Inspection by Date Final Inspection by Date v+ r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-366 ❑ Manteca 823-7104 ❑ Tracy 835-6385 V v Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO n + EH 13-24{DEV,ties) EH 14-29