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N 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 Ryles and Regulations of the San Joaquin Local Health District 96 Job Address C 16 �V� City y ti+�"�+�►'i'1 Lot Size PM Owner's Name +� � �T, I - Address Phone 1 c4i.,g Contractor7W � SdA� Address 3 -License No Phone O7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ industrial T ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R + -� $< Dia of Well-Casing Domestic/Private ❑ Gravel Pack LlTracy Type of Casing y Specifications [I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I r ❑ Irrigation _--Approx. Depth Y Eastern S ace Seal Installed by Repair Work Done X Type of PumpH.P. State Work Done Well Destruction 71Well Diam�eter Sealing Material atop 50a:1 Depth Filler Material {Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is C available within 200 feet.l Installation will serve: Residence CoFnmercial r'' Other (-4 Number of living units: NumbeFof.bedrooms 4 Character of soil to a depth of 3 feet: t i Water table depth v f r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ } Method of Disposak l Distance to nearest: Well Foundationf Property Line r LEACHING LINE ❑ No. & Length of lines r Total length/size # FILTER BED ❑ Distance to nearest: Well Foundation Property Line � .,.- ✓ SEEPAGE PITS O_Depth, -Size=--. SUMPS a�o Y1 Distance to nearest: Well Foundation Property Line a615POSAL 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 to become subject to workman's compensation laws of California." Contractor's hiring or suit-contracting signature certifies the following:"I certify that in the performance of th6,work.for which this permit is issued, I shall employ persons subject to workman's compensa- �> .tion laws of California." The applica vst call for all freqit ins ons. Complete drawing on rse side. Signed Title: / Date: FOR DEPARTMENT USE ONLY Application Accepted by ` Date Area Z 2�- �� ' Pit or Grout Inspection by Date Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED CA # INFO RECEIVED BY DATE PER "NO CC [y]PER r + EH 4 4REv.1/85) ( p �^'LV' _ J�3Q' EH 13-2 -