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z APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE:, STOCKTON, CA Telephone (209) 466-6781 t J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I .. : ` .. (Complete in Triplicate) I 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.,- Job Address 410 � City 444 Lot Size PM Owner's Name / �`�� "� Address �a �Z Phone Contractor / Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑:o DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ A OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES biSPOS,4L FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private; ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal k Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed Repair Work Done {,❑ Type of Pump H.P. State Work Done Well Destruction I❑ Well Diameter Sealing.Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 0-(No septic system permitted if public sewer is , available within 200 feet.) n) Installation will serve: Residence—1 Commercial_ Other 1f Number of living units: Number of bedrooms Character of soil to a depth of 3 feed Water table depth SEPTIC TANK ❑ Type/Mfg / Capacity No. Compartments PKG. TREATMENT PLT. ❑ �. _ Method of Disposal �4 Distance to nearest: (Nell Foundation Property Line "a LEACHING LINE No. & Length of lines Totallength/site W //� FILTER BED ❑ Distance to nearest: Well—/}z .----- Foundation Property Line SEEPAGE PITS ❑ Depth f Size Number SUMPS ❑ Distance°to nearest: Well FoundationProperty Line DISPOSAL PONDS ❑ 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 foi which this permit 1s•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 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 California." .I # The applicant mu call for all quired i lets drawing on reverse s Signed Title:��// /� Date: �, ! C h MR DEPARTMENT USE ONLY =l/f Application Accepted by Date Area Pit or Grout Inspection by Date 'Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applican� t_ Return all copies to: Environmenta)_Health.Permit/Services-I60]_E._Hazehon.Ave.,.P-.O.-Box-2009, Stk-.,--CA 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT,NO. + EH 13-24(REV.1/a 5) 7�• /lJa� �� f�7 I. EH 14-28 F" d