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F 41 , APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' ;f Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED >. !� (Complete .in.Triplicate} u { ; 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 Address3&1 F_ 4 Cl/EL"T r �Ci !' �- Q.S - ty �ir'JU Lot Size �00X PM Owner's Name Address T ` Phone ContractoAddress License No.o2� 4�9.3 Phone (0&—_9(o0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP N5TALLATION,.C2:�,, .. r. s-s_ SYSTEM REPAIR ❑ OTHER E3DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE _FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack I ❑.T acy Type of Casing Specifications ❑ Public ❑ Other El-delta, Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑Eastern __Surface Seat Installed.by Repair Work Done El Pump H•P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 (' Depth r 1K Filter Material (Below 501 ! TYPE OF SEPTIC WORK: NEW INSTALLATION 111117REPAIR/ADDITION`❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_Z Commercial= Other Number of living units: � I Number of bedrooms_r Character of soil to a depth of 3 feet: "0Z E, € -- !k+/ Water table depth a SEPTIC TANK ■ Type/Mfg ED W170� ., Capacity" OO CNo Coriipartments 1 ; R PKG. TREATMENT PLT. ❑ \Method,of Disposal Distance to nearest: Well Foundation G P;roperty;•Line,_.2 O LEACHING LINE ❑ No. & Length'of lines -. � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f � SEEPAGE PITS ❑ Depth ' Size Number SUMPS LlDistance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ �! f ':'# ! 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.` I 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 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify the 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." ii 1 j Ir The ap ant must call for all required inspections. Complete drawing an reverse side. signed - r itle _ Date: �'Q FOR DEPARTMENT USE ONLY Application Accepted by �M> _.._-..._.. Date Area Pit or Grout Inspection by Date Final Inspection by rrDate Additional Comments: h �k. 4W6781 ❑ Lodi', 369-3621 ❑ Manteca 82.3-7104 ❑ Tracy- 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE f INFO AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED'BY DATE PERMIT-NO. 1::, + EH13-24(REV.tie5) EH 1128