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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 /..L�./ '� City kovo Lot Size PM Owner's Name L M Address M-4- Phan 6f.577 s Contractor ve G Address —i2O 4L7—. -�` License No. Y03_17� TYPE OF WELL/PUMP: / NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PP 4NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO-NEAREST: SEPTIG TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS yr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION J4,01DESTRUCTION I I (No septic system permitted if public sewer is I e / available within 200 feet.) Installation will serve: • Residence_ Commercial_ Other Number of living units: _-L Number of e ooms I 'n t Character of soil to a depth of 3 feet: A4 � Water table depth s V ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT: ❑ Method of Disposal 1. Distance to nearest: Well Foundation Property Line LEACHING LINE �No. & Length of lines �,� Total length/size �j�r I {1� FILTER BED ❑ Distance to nearest: Well_ Foundation.�;sD( Property Line 74 SEEPAGE PITS l Depth r2S I Size Number SUMPS 0 Distance to nearest: Well /,$S 1 Foundation_ Property Line . DISPOSAL PONDS ❑ hereby certify that I have prepared this application and tflat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dt"ltrict. 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 t'-o rkman:s compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "Fcertify that in the performance of the'4v6rk for.wh(ch this permit is issued, I shall employ persons subject fo workman's compensa- tion laws of California."i 1 The applicant ust call or ail requir ins ctions. Complete drawing on reverse side. Signed Title: � �- - Date: OR DEPARTMENT USE ONLY _ I Application Accepted by /I Date ` Area Pit or Grout Inspection by, Date Final Inspectionyby Dat Additional Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMr1TED C H{� RECEIVED 6Y DATE PERMIT'NO. * (REV.tiK51 EH 14-28