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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E—)WETON AVE., STOCKTON, CA -Telephone (209) 466-6781 j 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 4Z7_25 ,y� _ City !S2UMC� •, 1 Lot Size PM Owner's Name 6_nA E1ZtLLT7,Address G*7.55 131:gL]ls=rt �?+]O Phone - 17 1 - ,, 5-9 Contractor Address License No.7^LL6(a_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSS INTENDED USE TYPE OF WELL PROBLEM AREA'-CONSTRUCTION SPECIFICATIONS Li Industrial Industrial -p'Open Bott �Cp:�Manteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack `❑ Tracy 6 Type Yof'Casing Specifications Ll Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —A `�W/t'~ ---Approx. Depth ❑ Eastern Surface Seal Installed,by. _ .a-......--.,.-._ _ _ .. Repair Work Done C Type of Pump H.P. State Work Done I r Well Destruction ❑ Well Diameter} Sealing Material {top 50'1 ^C- Depth _ ___ Filler Material (Below 501 ` ti-s '• +A TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONIJIJ�DESTRUCTION- ,(No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence_ Commercial, Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: + Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v PKG. TREATMENT PLT. ❑ Method of Disposal l r Distance to nearest: Well Foundation Property Line € ; �- LEACHING LINE'' ' ❑ 'No:& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; k I � SEEPAGE PITS ❑ Depth Size Number Z SUMPS ❑ Distance to.nearest:.-.,.Well .- - -,..Foundation Property Line DISPOSAL PONDS El 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:.`) i 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 wdrk'for which this permit is issued, I shall employ persons subject to workman's coinpensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ; Signed Title: .- �� M� pate: OR DEPARTMENT USE ONLY Application Accepted by Date f Area /t f/ Pit or Grout Inspection by Date Final Inspection by r Date �1 . Or{ Additional Comments: I'1 s l.'1� 1 I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 d6 Tracy 83 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE l INFO AMOUNT DUE AMOUNT REMITTED-- C RECEIVED BY DATE r PERMIT`NO. t + EH13-241REV.I/as) EH 1428