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APPLICATION FOR PERMIT . _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 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. TMs 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 fli'1 (� t I � CitLot Size ., PM Owner's Name ' Address Phone 621 " Contract& E- y CIfQI.�O Address- tL 3 /r7.�[ Z�Z License Na.� Phone' TYPE OF WELL/PUMP: .5-F NEW WELL F] WELL REPLACEMENT ❑ DESTRUCTION 171- i• -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ sem, DISTANCE'-70-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN TENDED 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of'Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Fille l (Below 50'1 i TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAI !ADDITION DESTRUCTION ❑ INo septic system permitted,if public sealer is• available within 200-feetJ Installation will serve: Residence_ Commercial_ Other Number of living units: —11�- Number Character of soil to a depth of 3 feet: Water tabletidepth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 4-f PKG. TREATMENT PLT. ❑ ,� Method of Disposal Distance to nearest: Well " Foundation-AffProperty Line LEACHING LINE No. & Length of lines A Total length/size FILTER BED ❑ Distance to,nearest: Well/ 6) Foundation .f ._ Property-Ohe s A SEEPAGE PITS EK Depth U,5 Size --V-1i _ urrJber ' SUMPS ❑ Distance to nearest: Well 2 L�7` Foundation Property Line _ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be d6rie 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 compensatf6h 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." The applica ust call f It r quired inspections. Complete drawing on reverse side tri 1 Signed _ Title: Date:_, ` FOR DEP RTMENT USE ONLY Application Accepted by Date Area / r /Pjt'or Grout Inspection by Date - i C-Final Inspection by ate I Additional Comments: `r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca—a8 7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV. EH 1428