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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 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 fs � ,� / 11-1-119 City Lot Size A00>(2-6 1J_ PM Owner's Name y&-, " 'f' Address . --� - _Phone Contractors Name �� ,.�� License No. �+s` �7! 3 Phone 146- F,107 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ L1.1 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 ❑ Open Bottom ❑ Manteca Dia. of,Well Excavation Dia. of Well Casing s ❑ Domestic/Private El Gravel Pack El Tracy Type of Casing Specifications S ❑ 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. tate-Work-Done--�-Y Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below ') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence -Commercial_ Other Number of living units: 00'. Number of bedrooms -3 �. Character of soil to a depth of 3 feet:—5-.,o9A1.0 Water table depth SEPTIC TANK ❑ Type/Mfg _A?,e4A'A Capacity No. Compartments � .i PKG. TREATMENT PLT. ❑ ` f � � Method of Disposal f Distance to nearest: Well Foundation /04 Property Line J< LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ,Size Number SUMPS. ❑ ' bistinde'to nearest: s—Well :. 'Fbundation 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 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." �° 1 The appiican call for all required inspection . Complete drawing on reverse s K � Signed Title: Date: 7 FOR PARTMENT USE ONLY Application Accepted by Znz Date Area Pit or Grout Inspection by tj 1A Datq Final Inspection by r %AlelDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601-E.-Hazelton-Ave-., P.O:—Box•2009,—Stk:-'CA-95201— FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY Y PATE PERMIT•'NO. + EH1324[REV.101631 EH 1428