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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-8781 PERMIT EXPIRES71t.YEAR FROM DATEASSUED ,t„ v (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. G Job Address E �� "�; ,•� � ,- QA .City . Lot Size PM t Owner's Name /1V Address e.. Phone //� 1� Contractor�f� Address 0. License No.,� X� Phone _146-OLOi., t TYPE OF WELL/PUMP: NEW WELL 1-1WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE . J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavations '""� ^^,of-Well Gasin ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `. t Specifications G~ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Irrigation Approx. Depth ❑ Eastern Surface Seal Installed b 6, Repair Work Done ElType of Pump H.P. State`Work Done_ 0 1. Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material )Below 501 _ t �- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION-'Ll (Nolseptic system permitted if public sewer is -t available'within-200,feet.i y� I .� : N Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms _5e 4 Character of soil to a depth of 3 feet: r�}� _�WatertablGep'h-^""''�""` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ k Method of Disposal Distance to nearest: Well Foundation Pr?iperty Line LEACHING LINE e` No"& Length of lines Z4Z Total length/si --I- _ 1- _ V F FILTER BED. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS N Depth � � ��.Size �� Number Q Z ** SUMPS ❑ , Distance to nearest: "WellFoundation Property Line DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the work will be done in accordance witK San Joaquin-eouryty•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 th!work for whictNhis permit is issued, I shall not t employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiiingl p_r sub-contracting signature certifies the following:•.,'I certify that in the performance of the,work for which this P er'mit is issued, I shall employ 6 "( p y persons subfect to workman's compensa- tion law5-otcGalifarnia.". j _ �:_.�.. .,��, ,� �► The appf b� t must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: ?l FOR DEPART ENT USE ONLY Application Accepted by Date ( Area Pit or'�,rout Inspection by Date Final'Inspection by Date C sf4'. Additional Comments: +{ _ r. _. 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. -El 4Q44Rrvv:ter