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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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4i I Job Address ' 6� - city Lot Size PM Owner's Name Address `1 1 , Phone � I Contracto f / ddress ansa N Phone L e� TYPE OF WELL/PUMP: NEW WELL oWELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION "rSYSTEM REPAIR Cl 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 ❑ In trial 1:1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications M Public F1 Other y ❑ Delta Depth of Grout Seal Type of Grout __ I I Irrigation __-Approx. Depth { I Eastern Surface Seal Installed by Repair Work Done ❑ Type of'Pump,r H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material (top 501 0 � v - N Depth Filler Material (Below 50') _ y TYPE OF SEPTIC WORK: NEW INSTALLATION'i 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is N available within 200 feet.) r�•h�, �- Installation will serve: Residence_ 'Commercial— Other • Number of living units: Number of bedrooms %1- _ t }. Character of sail to a depth of 3 feet: Water table depth M " SEPTIC TANK ❑ Type/Mfg Capacity-�- -- No.vCompartments �. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation t` 4 Pxoperty Line G LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Y1. -Property Line SEEPAGE PITS I I Depth Size Number SUMPS L-1 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 Ds%trict. �. Home owner or licensed agent's signature certifies the following: "I certify that in the performance_of the work fog which this permit is issued, I shall not employ any person in such manner-as to become subject to workmafis compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "l 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 mu fog al! required inspections. Complete drawing on rave side. �j�, Signed Title: Date: l "` FOR DEPARTMENT USE ONLY41 -�J /� f Application Accepted by DateW� Area_! Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ 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 95201 r i FEE AMOUNT DUE AMOUNT REMITTED�* CK INFO CASH RECEIVED BY DATE PERMIT NO. a.EH 13-24(REV,f/n5) EH 14-26