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APPLICATION FOR PERMIT gal SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 Gv l A 2 NS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED TH (Complete in Triplicate) Applicat�afp'via' �b,ltr1� an Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in comOW"Wtli `oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /� //,, yy. �J Job Address it is2- 0 4. r[..L�c, 4_06: / – 10 City 4" Lot Size PM � ~ �snfe ✓ gi- _ Phone / COwner's Name � Contractor f!li/eWd�_AW Address License Naa [x Phonew-4-4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEtift ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR JK 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of PumpH.P. _X" State Work Done Well Destruction ❑ Well Diameter .__M Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 5 Number of living units: Number of bedrooms t. 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 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 SEEPAGE PITS I I 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 Diltrict. 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." The applicant mu t call r required ins ctions. Complete drawing on reverse side. �j Signed Title:, /Q Date:Ir� �Z C.1 FOR DEPARTMENT USE ONLY �}7 Application Accepted by ( Date C) U o Area 06 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH 9 RECEIVED BY r DATE PERMIT'NO. +.EH 13-24(REV.i/A 5) `�� a�. EH 11-26