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F 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 fora 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. r >� �fJ T ► C,5 C GL IOM't Size �, /_1,tet Job Address City PM Owner's Name" , JQ eI 6) PAdclrss 17,P'7� S �11J��rl� Phone Contractor Address_ .(-eLEX�G License No. Phone TYPE OF WELL/PUMP: U NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ) ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Q Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence X Commercial_ Other r- '� Number of living units: Number of bedrooms �] of[7 Character of soil to a depth of 3 feet: 11 {� �_ �.. Water table depth 1 SEPTIC TANK ❑ Type/Mfg agaz No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Weil Foundation__,sem Property Line 30 LEACHING LINE -A<--No. & Length of lines >{ Total length/size FILTER BED Distance to nearest: Well Boa' ,�- FoundationQ_. Property Line SEEPAGE PITS ❑ Depth Tc t)l.,ti a Size 4,v P X10 Number SUMPS ><Distance to.nearest: Well Foundation_._- 6Q_.r Property Line 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 to become subject to workman's'compensatiori laws of California."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 Caf or ia." The applicant us call r all required M(�' Stions. Comp) to drawing on reverse side", T -� Signed l Title: � - - Date: l FOR-DEPARTMENT USE ONLY 1 Application Accepted by Date 46 Area Pit or Grout Inspection by Date -Final-- -Final Inspection by Date x _ .14. 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 FEEL700 NT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0, j INFO ` + EEH 3-24 H 1426IREV.I/a 57 �.� �i 11T6AL407 410..._. _a G •