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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA °. Telephone (209) 466-6781 a: °c PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c �f (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.1852 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City �4e_h�(Lot Size gf4e PM Owner's Name ��?erg �XL� �/',� w Address X4,61 e . Phone i s Contractor's_Name_ 4 ` )' License No. ��-J_ __ Phone TYPE OF WELL/PUMP:t NEW WELL ❑ WELL REPLACEMENT ❑'\ DESTRUCTION ❑ PUMP INSTALLATION,E] SYSTEM REPAIR ❑T� OTHER ❑ Y DISTANCE-TO NEAREST: SEPTIC TANK_ /kB _ SEWER LINES DISPOSAL FLD. 1.!f/PROP. LINE N G- rte ^ +t 9 FOUNDATION' WELL OTHER WELL 4) " PITS/SUMPS , INTENDED USE TYPE OF;WELL4 :PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom—, ❑ Manteca Dia. of Well Excavation /�. Dia. of Well Casing Domestic/Private Gravel Pack i c El Tracy Type of Casing 0`11 r6 Specifications f d o ' C7 Public Other 1 tC $Delta Depth of Grout Seal �f' Type of Grout E] irrigation _Aprox. Depth ❑ Eastern Su ace Seal Installed by i r Repair Work Done ❑ Type of Pump ' Sim H.P. � State Work Done t –� f � Well Destruction Ll Well Dia tem tem er' Sealing Materia! (top 50') V r Depth Filler Material (Below 501 f 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 of bedrooms vv�ll Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK 1❑ Type/Mfg I Capacity No. Compartments =' PKG. TREATMENT PL7I,❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' - LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1❑ Depth Size Number SUMPS '.❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I❑ C 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, I shall employ persons subject to workman's compensa- `ti6n laws of California."F j The applicant mustA for II fired in tiony. Complete drawing on revs a side. Signed Title: L}L�rDate: OR DEPARTMENT-USE ONLY 1 Application Accepted by Date '2 Area 7 Pit or Grout Inspection by ate Final Inspection by r p a 04, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFOAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PaE_RMIT"NO. +EH 13-24/REV.76!831 EH 1428