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w _Ap APPLICATJON FOR PERMIT fi SAN JOAQUIN LOCAL HEALTH DISTRICT,,,' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 q 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. I' Job Address City ifOpl Lot Size 20 trP PM Owner's Name ✓� _Address_= Phone & Contractor's Name eM oel&&H S d Akl' License No. g r-M q3 Phone g( - F6 G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ * I 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 1 ? ❑ Industrial 3 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications --n ❑ Public r ) ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation t —Approxi Depth ❑ Eastern Surface Seal installed.by Repair Work Done ❑ Type of Pump '�, H.P. State Work Done Well Destruction : ❑ ;._Weil-Diameter.- _..Sealing_Material_(top-50'1 - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system permitted if public sewer is m available within 200 feet.) _ Installation will serve: ResidenceCommercial!=Other m Number of living units:_,L_ Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth ee e C J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t i PKG. TREATMENT PLT. ❑ Method-of-Disposal '-- - -- Distance to nearest:j WeII Foundation Property Line r LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth-0MMk__ tea'' Size Number SUMPS i❑ Distance to nearest: Well Aedf Foundation /e Property Line c,r ` DISPOSAL PONDS Y❑ '. ,-1 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- t • t 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 Al 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." The applicant must call for all required ins ctions. gomplete drawing on reverse sj;icLe i Signed X Title:--- - - -- ----^^-� , Date: t FOR DEPARTMENT USE ONLY ,Application Accepted by Date rea Q Pit orfflia Inspection b i / pe Y Date Final Inspection by_ �Y 2�-.j/ Date11E 04 dditional Comments: ❑ Stk 466-6781' 0 Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental-Health-Permit/Services 1601-E-Hazelton Ave.-P:O Box-2009, Stk., CA 95201 r FEE f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. IAE.,.101831