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wM APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED , (Complete in Triplicate) Iia 4.W xz 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. [j Job Address O City aelm. Lot Size PM Owner's Name 1A0b4J.R4atJ�- ddress 2.342!!t �` // Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial LJ.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 Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIOWXNo septic system permitted if public sewer is Ui 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. El Method of Disposal w Distance-to nearest: Well Foundation Property Line � i LEACHING LINE ❑ No. & Length of dines Total length/size FILTER BED ❑ Distance to;nearest: Well Foundation Property Line t.-,- SEEPAGE PITS ❑ Depth Size Number SUMPS 17 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 District. ' Homeowner 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- tion laws of California." i . i"— ' " - - - - The applicant must call for all required inspections. Complete drawing on reverse side. Signed � Title: Date: F RTMENT USE ONLY i Application Accepted by .._ .. Date �-7 `� 1� Area O r Pit or Grout Inspection by Date Final Inspection Illy. Dat 4 JT Additional Comments: &/Yh-1�i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354YM Applicant—Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.ries) c Q � EH 14-28 '