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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1609,E. HAZE4TON 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 CityLot Size PM Owner's Nam e1` _ � � Address ` One f Contractor A Address G _License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ UMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA„ CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteda ----- Dia. of Well Excavation _ �- Dia. of Well Casing [-1Domestic/Private El Gravel Pack ElTracy--a Type of Casing � ' . Specifications ` ❑ Public ❑ Other -A: ❑ Delta Depth of Grout Sealy Type of Grout ❑ Irrigation --Approx.'.Depth ❑ Eastern 'Surface Seal Installed"by Repair Work Done ❑ Type of., m Pup s H.P. r State Work Done -M1 Well Destruction ❑ Well Diameter Searing Material (top 501 i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATI N LIREPAIR/ADDITIO DESTRUCTION EI (No septic system permitted if public sewer is II available within 200 feet.) Installation will serve: Residence Commercial__ Other Number of living units: --L Number of bedrooms T i Character of soil to a depth of 3 feet: Water table depth ®� i SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG, TREATMENT PLT. ❑ .a Method of Disposal ' Distance to nearest: Well Foundation Property Line i LEACHING LINE �W-j No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size f Number r SUMPS Distance to nearest: Well I-2TZ1 Foundation—1--id 9* Property Line F DISPOSAL PONDS ❑ --- 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 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 folbecome subject to workman's compensation laws of California."Contractors hiring or sub contracting signature certifies the following:"I certify tha -in the performance of he work for which this permit is issued, I shall employ persons subject to workman's compensa- e4 -,tion""laws of California." The-applicant t all for II required inspections. Complete drawing on reverse side. Si ned. Title: - "� Date: g G F DEPARTMENT USE ONLY --- . A lication Accepted0 -7 Date �� Area -7 Pit r Grout Inspection by• ' Date o1'L-0 Final Inspection by te 7 a�� Additional Comments: t ❑ Stk°T466-6781—U-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 85201 I FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. INFO J fty� + EH13-24MEV,1/05) `�Ir /1 l EH 1428 VV