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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J (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. t4-) Job Address 5 (0 City} +.,.y * L t Size PM Owner' ami__ 12=? PLEFT11 — Address _7Q -- w-4/ # Pfiionsea29 Contra r tS p Address�_-�1(4 ;Y E-064)M License Nor Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'S C]'!'t_ "PUMP INSTALLATION SYSTEM REPAIR ❑ `OTHER?EI` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 9 i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS VY ' INTENDED USES TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indystrial A' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t h�c.,"(omestic/Private' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other� " ❑ Delta � rorfa�S phf Gut Seal Type of Grout ❑ Irrigation ' �4pprox. D th ❑ Eastern Ie - lstalled by -- Repair Work.-Done El Type of Pump H.P. J State Work Don Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth '" Filler Material (Below 501 " 4`. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - + j7.''" available within 200 feet.) ti Installation will serve: Residence:'%- . Commercial— Other Y �` Number of living units: Number of bedrooms t i-Character-of soil..to a.di0ih_of_3_feet:_ Water-table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line } t " LEACHING LINE "- ❑"No. &-Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r f r SEEPAGE PITS ❑ Depth Size Number t .SUMPS ❑ 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 accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, t' 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 sub-contracting signature ? certifies the f awing:"I certify that in the rto mance the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of aliiornia." f The app li t ca for r ire i o late drawing ev side. a Signed ' Title Date: [�a q��n FOR DEP MENT USE ONLY Application Accepted by Date 4-7 Area Pit or Grout Inspection t Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE' PERMIT'NO. + EH'13.24{REV.7/957 EH 142b 7 '