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APPLICATION.FOR,PERMIT SAN JOAO,UIN,LOCAL HEALTH DISTRICT 1601 E. HAZEL TON-AVE., STOCKTON, CA Telephone 11209)461 ": :: ,;'� i 1 PERMIT EXPIRES, FROM DATE^ISSUED a ._„IComplete-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:TMs application is made.iwcompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump;and the Rules and Re ulations of the San Joaquin Local Health District ,,;f3f c f, , pry ,1 t, _- Job Address City Lot Size. 11 PM o - OwnName `` Y� � -+ -Address -- — �- ^T 'Y Phone er's 1 _ Contractor's Name /cs 9� License No. 2�'� — V3 Phone 6 6 9'&07 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS :❑ Industrial t❑-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 � Type of Grout� S ❑ Irrigation -L-Approx. Depth ❑ Eastern Surface Seal Installed by � Repair Work Done ` ❑ Type of Pump H,P. State Work Done �J Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Belo ') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ir DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.), Installation will sere: Residence��Commercial_ Others Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: �y Water table depth SEPTIC TANK LI' ,Type/Mfg ^4a xlc'6 Ic-1 Capacity Z b 6 No, Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal �— Distance to nearest: Well �� Fou dation RC1 Property Line ! � LEACHING LINE ❑ No. & Length of lines Total len gth/size FILTER BED ElDistance to nearest: Well Foii Property Line Lj SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ ,Distance td nearest: WellA 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. 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 following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applican call for all required inspec' S. pg drawing on reveid 1 . Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r= y.Area f'it or Grout Inspection by Date Final Inspection by Date? o Additional Comments: ❑ Stk 466-6781 EI Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permlt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO; AMOUNT DUE AMOUNT REMITTED .'CCKSH RECEIVED BY - DATE PERMIT"NO. + EH 1324[REV.101831 EH 1425 1