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k " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED IComplete in Triplicate) Application is.heieby 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 Address de 0 City Lot ' e PM Owner's Name CAA4 I16��Z Address /A " , Phone Contractor Address d� _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 1 1-1 Public t❑ Other . ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation �.Approx. Depth l I Eastern Surface Seal Installed by Repair Work(Jane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ i Well Diameter Sealing Material (top '1 �op 50 Depth _ — Filler-Material�IBeibiry 50;1 _ !� TYPE OF SEPTIC WORK: NEW INST.ALLA710N REPAIR/ADDITION I I DESTRUCTION I I INo septic system=peemitted if public sewer is U available within 2004et.I (A Installation will serve: Residence, -'Commercial--�ther- - Number of living units: Number of bedrooms -- •"' ! p} of soil to a depth of 3 feet S Water table depth7&- Character f / SEPTIC TANK ! 171' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT:❑ ] I Method of Disp9sal Distance to nearest: Well �� Foundation ..___. Property Line LEACHING LINE No. & Length of lines f Total length/size FILTER'BED ❑ Distancetonearest: Well Foundation_..._--- Property Line SEEPAGE PITS 11 Depth Size �� Nymber �. V r E?istance to nearest: Well�_ foundation Property Line E, DISPOSAL PONDS [2s I - F 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 of licensed agent's signature certifiesi e 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 becomes I3ject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies t following:.."!certify that in ha perform c�eof the work forwhichthis permit is issued, I shall employ persons subject to workman's compensa- tion laws l,fornia." iThe applicant st call fora req 'red i pe ions. plete drawing on reverse side. Signed Title: Date: Z 8 v i OR ARTMENT USE ONLY l2 I' Application Accepted by Date �I Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Enviro}}nmental Health Permit/Services 1601 E. Hazelton Ave., P.O:Box 2009, Stk., CA 95201 1 r 'FEEAMOUNT DUE: AMOUNT REMITTED K RECEIVED BY DATE PERMIT•NO. ? I INFO + EH 13-24(REV.1111.5) .,.sr ..- ...-�..:•--, - —-a-+rte-^^..-'�„^^..` - -.- �/r� EH 14-28 1 t