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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address�W0000 KASSdIV M Sa.j 3v0Gu,.v R%JW di city Lot Size 60 1d7� � PM Owner's Name IA,x44- Ma e6ka Address 46T I-B4 1 Phone Contractor Po`�P `�� Address 46M W+IS oa (.J9 License No.Z.5'4– 3y,3 Phone 41-4 409 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS G 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 tr ❑ 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 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION SL DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_)L Commercial_ Other Number of living units:_A_ Number of bedrooms I Character of soil to a depth of 3 feet:�Iqa e e,F .� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of isposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines `—r Z 5* Total length/size 2L2. FILTER BED Ilii Distance to nearest: Well Foundation 2'S i Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. 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,(;,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 workma"compensa- tion laws of California." . The applicant must call for all required inspections. Complete drawing on reverse side. Signed X � r � Title: fS; Date: / FOR DEPARTMENT USE ONLY Application Accepted by � CAV-) Date Area Pit or Grout Inspection by _ Date Final Inspecti n by Date Additional Comments: MPG ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. IPNzelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. + (REV.1/85) EH 14-26