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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 ou Agier r-1 City_AC.4i97eD Lot Sizetea? 09 U2GS PM Owner's Name Address Phone X283 1 ContractOr < 13 Address License No. Phone_ A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _� OTHER ❑ A 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 DQ ❑ Industrial ❑ Open Bottom ❑ Manteca!f Dia. of Well Excavation' Dia. of Well Casing ❑ Domestic/Private Q Gravel Pack ❑ Tracy Z Type of Casing r Specifications W ❑ Public ❑ Other F-1DeltaDepth of Grout Seal Type of Grout ❑ 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'} 1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_X_ Commercial— Other Number of living units: J...._— Number of bedrooms�_ Character of soil to a depth of 3 feet: Aft-hPAS t a Water table depth 2 SEPTIC TANK ❑ Type/MfgC�i�city, ��, No. Compartments PKG. TREATMENT PLT. ❑ '��` ( ` Method of Disposal--- Distance isposahDistance to nearest: Well Foundation *" "Pi-opeity Line r l Total l LEACHING LINE N No. & Length of lines 40` ` t `r ength/size 4o` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ` ■ Depth .2� Size Number - SUMPS ❑ Distance to nearest: Well f �__._ Foundation /LfQ""^_property Line z�� DISPOSAL PONDS ❑ v I hereby certify that I have prepared this application and that the work will be dote 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." 1 The applic nt must call for all required inspections. Complete drawing on reverse side. s �1 ' Signed �.� Title: ' Date: f - 1P #-. FOR DEPARTMENT USE ONLY Applifcation Accepted by Q Date" it tInspection �p 6Area Grout Y Ins ection b �✓A � p ate�-- Final Inspection by Date3i Additional Comments: "I ❑ 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 AMOUNT DUE AMOUNT REMITTED ' '• CK �"1tECEIVED BY DATE PERMIT NO. INFO CASH + EH1 -24fREV.FiHs1 �. OU EH 1428 3-�F—k(o �/'f/ IY