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APPLICATION FOR PERMIT �( SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 sewag r No. 1862 for well/pd the Rules and Regulations of the San Joaquin Local Health District. Q 1 Job Address city Lot Size PM J Owner's Name t Address + ' �' a Phone y � 4 .#'moi J , ' r � 4 L j Contractor ddress [3.] ~� License No. A�Phone 1. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SY EM REPAIR ❑ OTHER ❑ ; DISTANCE.TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULT WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial$ ❑,cOpenTBottom __, [7_Manteca�___ . wDia._of WeII Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s - C"1 Puolic t ❑ Other 71 Delta Depth of Grout-Seat----- - -"' Type of Grout E I:Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done [I Type of Pump P. State Work Done Well Destruction ❑ Well DiameterF ealing Material (top 50') " 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I TINo septic system permitt d if public sewer is available withi feet. Installation will serve: I Residence_ Commercial_ _ :Other r Number of living unrtsr Number of bedrooms / �y/� IuTt� 9 Character of soil to a depth of 3 feet: ' w Water table depth SEPTIC TANK 10 Type/Mfg, Capacity No. Compartments OF PKG. TREATMENT„P.LTI1J Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of limes Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 1 Depth Size _ Number € SUMPS }-L-].—Distance-to-nearest:-»--WeII-n=t.---Foundation----Property Line I DISPOSAL PONDS ❑ 111 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 Sart Joaquin Local Health Di§trict. 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 i 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 rrAst call for all r rred inspe ions. Complete drawing on reverse side. " cru �y Signed X_ - Title: Date: -'v �Z F R DEPARTMENT USE ONLY 12-4 Application Accepted by Data Area r � 1 Pit or Grout Inspection by D Final Inspection by Date Additional Comments: lid ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEI1 E0 aY INFO DATE PERMIT'NO. �. ..EH 13-24 tFIVV.I H 57 �7 �rd,'2gb i EH 14-2a —T--� ��'444( 1