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a _ APPLICATION FOR PERMIT ��-• u SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is heieby 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. (/ t Job Address City_ fI��/(60 4/Lot Size �.xr X PM P Owner's Name /r / , k /=�d}fross �_ _ d t G`�s� Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other C] Delta Depth of Grout Seal Type of Grout ` ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by I4 Repair Work Done' ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material 18elow 501 o TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ FIEPAIR/ADDITION ❑ DESTRUCTION fNo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial— Other l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 11 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property 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 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 cortifies 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 must call for all required inspections. omplete drawing on reverse side. Signed X ._ Title: -�` Date: ^ FOR DEPARTMENT USE ONLY I Application Accepted by Date ��- Area F r � Pit or Grout Insp tion by _ DateaLlraspec�—by----- Date r Additional Commenr4.4 `z C1 (6- Stk 46781 Lodi -3621 1771Mant ca 823-7104 c - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazel#a -_ve.,—2009;Stk77-GA-95241 1 INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. + Eli 13-24(REV. li . EH 14-28 k .