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APPLICATION FOR PERMIT ` ., SAN JOAQUIN LOCAL HEi4LTF1�DIST,RlCf,1. �, S� 1601 E,r\HAZEL.TON AVE., STOCKTON, CA I Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f 1Complete 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 /Vr, City Lot Size PM ' Owner's Name a ',e 2TTeIVIA11 Address ��r E�!/ `/l 7 Phone i Contractor -5�dress License No. Phone., TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION E] i PUMP IISTALLfATION� SYSTEM REPAIR ❑ OTHER ❑ I ` DISTANCE TO NEAREST: SEPTIC;TANK �� SEWER LINES DISPOSAL FLD. PROP. LINE L� FOUNDAT C) 7" AGRICULTURE WELL OTHER WELL PITS/SUMPS -f INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing, Domestic/Private ravel,lrack ❑ Tracy T fb r ? Type of Casing �� Specifications 1:1 Public ❑ Other f w ❑ Delta Depth of Grout Seal T of Grout G ❑ Irrigation ;124porox. Depth ❑ Eastern Surf a Seal Installed by s Repair Work Dane ❑ Type of Pump _ H.P.�� ,.._, State Work Done Well Destruction ClWell Diameter 1 Sealing Material (top 50') Depth' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Cl (No septic system permitted if public sewer is " i � i available within 200 feet.) ) Installation will serve: Residenlge_' commercial_ Other Number of living units: IKkumber bf bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ TypeZMfg, Capacity No. Compartments + PKG. TREATMENT PLT. ❑ X � Method of Disposal Distance to eareat: Welly Foundation Property Line 6 } LEACHING-LIN'E��I ❑ No� & Leng# of 1'h� -�ihr - Total length/size I FILTER BED ��-�,, ❑ Dis�ance to nearest�� ! t1i � � � Foundation Property Line 1 SEEPAGE PITS El 64th 11�Sizer -- ' � ,Number SUMPS EJ Distance to near'eW .Wfuw"_ Foundation.._.�.�_� Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that�the work will be done in aCcord'ance with San Joaquin county ordinances,,state laws, and rules and regulations of the San Ioaquin Local�Health-,bistr`'1 . Home owner or licensed agent's signature certifW,,tha-following."I certify that in the performance of the work for which this permit is issued,'l shall not employ any person in such manner as to become subject to workfnan's compensation laws of 61ifornia."Contractor's hiring or sub-cGntracting signature certifies the following:"I certify that in the performance of the workffor which this permit is issuey pa d, I shall employ subject to woIrkmn's compensa- tion laws of California." ` The applicant mfor All require s tions. Complete drawing on ve ide. Signed Title: \ Date: F R DENT USE ONLY Application Accepted by N�JC �. �M,,,�Zr, i Data U `�_'DV Area j Pit or Grout Inspection by zf C---.,CAC r0-. Date IT? nal Inspection by Date Additional Comments: I v I ❑ Stk 466-6781 ❑ Lodi, 1369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Perrrlit/ enrioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINF AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT;NOI + EH 1124(REV.I/as) EH 14-25 OS