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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 tea-. (Complete in'4Triplicate) 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. 11 f c Job Address-,��/ f Ci J `` Lot Size PM { +3 �W `'n� Owner's Name t AddressPhone j 3 Q� 7 Contract aert,tl C Address P-0- �'7 -i License No.3!ZKZ7{Z C, Phone �1-ct TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ^ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4_ OTHER ❑ L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL t OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 13Public ❑ 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 ❑ Well Diameter Sealing Material {top 501 # Depth Filler Material (Below 501 6 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other ' Number of living units: _/__ Number f bedrooms r Character of soil to a depth of 3 feet: +-t d Water table depth (00 SEPTIC TANK ❑ Type/Mfg U Capacity— No.'Compartments PKG. TREATMENT PLT. ❑ "Method of Disposal J Distance to nearest: Well Foundation - Property Line LEACHING LINE P"'No. & Length of lines f 'Total length/size FILTER BED ❑ Distance to nearest_ Well--:5Q _ Foundation f_10_� Property Line s SEEPAGE PITS r❑ Depth Size o2 x 10 1 Number � SUMPS } ' Distance to nearest: Well Foundation,,l0 r Property Line _�5 DISPOSAL PONDS :❑ �T 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 Joagdin'Local Health District. i 1. 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."Contractors hiririg'or sub-contracting signature r certifies the following:"1 certify that in the performance of the work for,which this parmit is issued, l-shall employ persons subject to workman's compensa- tion laws of California." - �` k" '�� - ;• i `•' !€ The'applicant must call for all required inspections. Complete drawing om�eves{eFside.V` 1 Signed r Title: 1( �. Date: 1 1 FOR DEP RTMENT USE ONLY A lication Accepted by Date Area o rouT Inspection by Date '-Final Inspection-by Data �-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 t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. i i +EH13-24 MEV.1/05) EH 1426 1p7 I