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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address f CityG Lot Size PM Owner's Name &A t! Address S� phone YF Contractor -w�l G P z Address 0 .1!4 License No.aCaPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,[] DESTRUCTION ❑ -`PUMP INSTALLATION ❑ SYSTEM REPAIR ❑" — OTHER i] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES k _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal" Type of Grout ❑ Irrigation L--Approx. Depth ❑ Eastern Surface Seal Installed by ■' Repair Work Done ❑ Type of Pum t r } I ,1C1 Yp p H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top,50'1.__ S Depot Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence V� Commercial_ Other Number of living units J__ Numb- of bedrooms•• i Character of soil to a depth.of_3-feel: C A dy;_Lnoyn Water table depth Q SEPTIC TANK ElType/Mfg Capacity No. Compartments 1 PKG, TREATMENT PLT, ❑ k ' Method of Disposal Distance to nearest: Well Foundation Property Line Y LEACHING LINE .;No- & Length of lines ��_ Total length/sizellL FILTER BED ❑ Distance to nearest: Well-0O Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 0 SUMPS ' ❑ Distance to nearest: WellFoundation L Property Line DISPOSAL PONDS ❑ ] t l. 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 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 must call for all re inspections. Complete drawing on reverse side. K Signed X jl/ Title: _ _ ' �6 � &atDade: FOR DEPARTMENT USE ONLY /� / Application Accepted by Date GY 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 ' 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 0 RECEIVED BY DATE PERMIT NO. + EH 13-24(REV,1/n5) - /r EH 1428