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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 app' ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and he Rules and Regulations of the Sr Joaquin Local Health District. S POW Job Address L City at Size M Owner's Name Address /_=f� F.�t Phone Contractor's Nai AMR,. �` Phone TYPE OF WELL/PUMP: NEW WELL,,Q WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 :3"CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 4. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications w ❑ Public ❑ Other ❑ 4elta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Puinp H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Maferial {top 50'1 Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r t available within 200 feet.) Installation will serve: Residence Commercial— Other '._'t. Number of living units:/ Number of bedrooms g� ' 1 � s'41; f Character of soil to a�epth of 3 feet: Water table depth SEPTIC TANK [ Type/Mfg - �eapacity o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel ' Foundation ltr) Property Line 1 ..t LEACHING LINE No. & Length of lines /�,To�tal length/size FILTER BED 11 Distance to nearest: Well 7f• Foundation_ ZO Property Line SEEPAGE PITS Depth 5 Size Number i SUMPS ❑ 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,I shall employ persons subject to workman's compensa- tion laws of California." Thg.appflc ant m St call for-all requirgdfinspej'ions. Comp-[pte dra%yi?g-oQ.Jgverse side. Signe Titl `i rt~ �� Date' (741- FOR DEPART ENT USE ONLY 2 Application Accepted by pate �I �� Area Pit r Grout Inspection by ate -a 5. Final Ins- ction by at, Ad •ional Comments: 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A licant- 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. 4 (REV,10/931 EH 1426