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APPLICATION FOR PERMIT -SAN JOAQUIN LOCAL HEALTH DISTR,::��, 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplica#e) 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. f r Job Address "� w ?t City f{ Lot Size c- PM Owner's Name 1w, , Address I U FF L _ Phone -3(e? 't:14 Contractor 6111900AS&19-11 Pei)biLla Address eL z445"Li~E4 k C Aey Ed License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -/1,0 SEWER LINES 10 t? DISPOSAL FLD.1t5 PROP. LINE FOUNDATION i,'�P AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial A Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingTF--e4= Specifications J I'1 Public Cl Other Cl Delta Depth of Grout Seal tel?f Type,pf Grout� �Jcl.6 ceA7e.`2 e Ft._f I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by&JO - l 11644 Es Repair Work Done ❑ Type of Pump a H.P. State Work Done_ Well Destruction ❑ Well Diameter Seating Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION I I (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS it Depth Size _ Number SUMPS L1 Distance to nearest: Well 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 Dt%trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fdr which this permit is issued, i shalt 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- tion laws of California." The applicant must call for if requir d inspections. Complete drawing on reverse side. Signed X_ , Title: Date: FOR DEPARTMENT USE ONLY �7 Applicatto Accepted by Date / Area Pit or rau Inspection by � Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE �,Q INFO AMOUNT'DUE AMOUNT REMITTED CASH RECEIVED BY DATE P RMiT NO. +-EH 1124(REV.f/H 5) EH 1429