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�.` APPLICATION FOR PERMIT .. SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA kTelephone (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. Job Address City "+2 Lot Size x �2 PM�� l Owner's Name Address P�. (y ail Phone -7Z 8 Contractor Address.35Z6 PEA A z 6 z 40 dc, '_icense No. 110 (y/3 Phone J�� Y15 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1190 " . 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 71 Dia. of Well Casing Domestic/Private Gravel Pack X Tracy Type of Casing le Ve— Specifications i ❑ Public El Other ❑ Delta (Depth of Grout Seal Type of G ut ❑ Irrigation ---Approx. Depth ❑ Eastern P.Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State'Work Done I CA Well Destruction ❑ Well Diameter Sealing Material (top 501 +� Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADQITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth { SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. ❑ ., Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/.size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,t SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E 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, 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 f certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to-workman's compensa- tion laws of California." The applicant ust call for all requi inspections- C mplete drawing on reverse ide. S' Signed Title: Date: ` FOR DEP TME USE ONL Application Accepted byData !� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi.. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Sarvices1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`'NO. INFO / C� + EH 13-241REV.1/051 EH 1426 i • 1