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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 sa City L'ot Size PM � eGS Phone Owner's Name - fie✓ 2�c ��r/ +y/d r/- R�3 Contracto sst ? i' LR!7L9 License No. 1 Phone TYPE OF WELL/PUMP: NEW WELL)k WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ho SEWER LINES DISPOSAL FLD. PROP. LINE12 FOUNDATION 12._ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 171Manteca Dia. of Well Excavation Dia- of Well Casing JW'Domestic/Private ;4 Gravel Pack ❑ Tracy Type of Casing03Yq 4DW Specifications f'l Public C1 Other Ll Delta .Depth of Grout Seal ,� j�7 _� Type of Grout t I Irrigation `ZWpprox. Depth „ t-1 Eastern Surface Seal Installed by—,?.0tr,,1/�t' - Repair Work Hone ❑ Type of Pump [.i — H.P. State Work Done Well Destruction ❑ Well Diameter 1., Sealing Material Itop 50'1 -- Depth_2—G,o Filler Material ISelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) d Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms T E Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg x Capacity No. Compartments PKG. TREATMENT PLT- ❑ i . i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS I I' Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line , DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accdrdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 4. 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 Califotnia." 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, I shall employ persons subject to workman's compensa- tion_laws.of.California.y� -.1 The applicant.must call for all required inspections. Complete drawing on revers side. Si gneQ X Title: e_ r Date: FELQ--_ARTMENT USE ONLY Ukry `� �"� Application Accepted by _ Area Date Pit or Grout Inspection by _Date �� Final Inspection by Rate Additional Comments: _ ❑ Stk 466-6781 Q 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 s FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEI?BY DATE PERMIT'NO. IN C SH r a.EH 13-24 iREV.1/K 51 EH 14-26