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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 19 30 HIAWATHA" city .STOCKTON Lot Sae PM Owner's Name # Address 1930 AWA Phone 462-0250 Contractor Address License N6.,.__20222_8_Phone 463-1706 TYPE OF WELL/PUMP:' '4� �` 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well'Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Othfer ❑ Delta yDepth,-,of Grout.5eal Type of Grout k ❑ Irrigation __Approx. Depth ❑ Eastern Surface.5eal,lnstalled-by. -- - } Repair Work Done ElType of Pump r ~ H.P. State Work Done 9 Well Destruction ❑ Well;Diameter " _ Sealing M erial (top 501 I W Depthl i I J Filler Material (Below 50,), TYPE OF SEPTIC WORK: NEW INSTALLATION ❑i, REPAIWADDITION.C7 DESTRUCTION iNo septic system permitted if public sewer is , ,. __,-= .:x.� available thin 2 feet) w Installation will serve: Residence Commercial` Other Number of living units: C11 Number of bedrooms Al's " f { Character of soil to a depth of'3 feet: SEPTIC TANK Type'/�Mf > --` - — -- Water tab depth ,^ " ' y "• � "� 4 No. Compartments �� ❑� _ Ca Pacityp PKG. TREATMENT PLT. ElW�'w� `z.;""� Method of Disposal �� Distance to nearest: Well Foundation Property Line i l( LEACHING LINE ❑ No� & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well 4`: Foundation Property Line re' SEEPAGE PITS 1-1DepthSize Number SUMPS 0 Distancer to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that,th;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." A � i The applicant ust call for all r quuT inspections. Complete drawing on reverse side. j Signed X vTitle: PRRSIDENT Date: 312 5187 h FOR DEPARTMENT USE ONLY QOApplication Accepted by Date �` 7 Area Pit or Grout Inspection b Date Final Inspection by Date Additional Comment— El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appiicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDZK RECEIVED BY DATE PERMIT N0. k INFO Y + EH 13-241REV.iiy51 O Q '� / / EH 1426