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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 IComplete 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. e Job Address 9613 ' JN ��'rP City Lot Size `—� PM //��,�� �� I Owner's NamNZ4 "1 Address Phone . Contractor [ [! / Addres�l/ Z icense No. � PhonJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION X '"T`"`^- PUMP INSTALLATION-0- --SYSTEM-REPAIR ❑- OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, "' DISPOSAL FLD. PROP. LINE yFOUNDATION —',AGRICULTURE WELL-,—. OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom s j i Manteca' '`' Dia: of Well-Excavation'. Dia. of Well Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation ` --Approx. Depth I i Eastern Surface Seal Installed by - s Repair Work Done ❑ Type of Pump, H.P. Stat .Work Done _ Well Destruction r AI Well Diameter _,I// Sealing Material Itop 50') • Depth_ �� " ate. �' ;.4 Filler Material )Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 RFPAIR/ADDITION f I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial l Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: 1 fi Water table depth ! SEPTIC TANK ❑ Type/Mfg I f Capacity No. Compartments I PKG. TREATMENT PLT. F] I r Method of Disposal IF 1 Distance to nearest: /Well Foundation Property Line 1 k LEACHING LINE Cl No. & Length of lines ' Total length/size FILTER BED` """"LJ,--Distance,to nearest: "�-Well""" Foundation 'Property Cine""' w SEEPAGE PITS„� . I I Depth `M Size i Number w _SUMPS— ---- l Distance to nea're'st:-Well�=Foundation-r """'Property-Line DISPOSAL PONDS ❑ I hereby certify that l 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 Di§trict. 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 I 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." I The applica t ust Ii for all r qu'lrednsspections. Complete drawing own-+reverse 'do. / Q Signed X l+ Lam'. v Title: [�'�'� � �" Date:/�iJL �f J FOR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO CASH +•EH 13-24 1 REV.i i H 5) O ,� EH 14-26