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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 Local Health District. Job Address 27 10A / [� Ciry L- Loi Size 1.- PM Owner's Name 5 L SNC( Address V A Phone Contractor eel TW - CAO$.S Address /'() f3 N License No.322S$S Phone3l�`-- TYPE OF WELL/PUMP: NEW WELLW WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONX SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKz / Ea 40— SEWER-LINES DISPOSAL FLD. PROP. LINE 't-0 FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation d Dia. of Well Casing Domestic!Private .-;W Gravel Pack ❑ Tracy Type of Casing 00 i-IC Specifications ❑ Public '❑ Other ❑ pelta Depth of Grout Seal 40d Type of Grout CeAkAj--f ❑ Irrigation `, _�Approx. Depth ❑ Eastern Surface Seal Installed by_CQli,rTA_A��jn Repair Work Done ❑ Type of Pumps_V�F"� H.P, State Work Done Well Destruction ❑ - Well.Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION ❑ DESTRUCTION EI (No septic system permitted if public sewer is } I available within 200 feet.) Installation will serve: #residence— Commercial— Other Number of living units: Number of bedrooms (� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLTA!, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE `-❑ No. & Length of lines _. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation i Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearestr -Well---- -- -Foundation Property Line DISPOSAL PONDS ❑ I = 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 ttie 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 subjectio`workman's compensation laws of California."Contractors 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." I The applicant must call for all required inspections. Complete drawing on reverse side. Signed X iiat Title: i Date: i(a' FOR DEPARTMENT USE ONLY Application Accepted by Date s r¢ / Area 1 Pit or Grout Inspection by 1 {� f Dat/ Final Inspection by pate ! Additional Comments: �� 'n^'t' o'a �f `t' a It Sem 5' //t�� ni EJStk 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 AMOUNT DUE AMOUNT REMITTED INFO 1 RECEIVED BY DATE PERMIT'NO. t EH 13-24(REV.iiH5) ! 0�� EH 1428