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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FRO M'.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 -- : _IV"� Ma AK,1 -1A,- ' " City Loon Size PM Owner'sNamed " ' '!tet" `L�!'] ddressne Contractor Address License No. Phone TYPE OF WELL/PUMP: !i NEW WELL ❑ WELL REPLACEMENT ❑" DESTRUCTION ❑ PUMP,iINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'❑ .� DISTANCE TO NEAREST: SEPTIC TAMC ' SEWER LINES DISPOSAL FLD. PROP. LINE ri FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS .� i }Y "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 ❑ Public ❑ Other *❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t i Repair Work Done ❑ Type of Pump `H:.P� € State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ` lx\ Depth ' Filler Material (Below 50') 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 Commercial_ Other Number of living units: ; Number of bedrooms / d� Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK T ypIe/Mfg t?`f 5 Capacity ��0 No. Comp r[ments PKG. TREATMENT PLT. ❑ PJ[R. Method of Disposal e Distance to nearest: Well /40'6—'_ Foundation Property Line_ LEACHING LINE No''& Length of lines Tytal length/size FILTER BED ❑ Distance to nearest: Well/42a Foundation/� Property Line SEEPAGE PITS ❑ "Dep!th Size Number t SUMPS ❑ Distance to nearest: Well Foundation Property Line g DISPOSAL PONDS Cl 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 Californ'ia."Contractor's hieing or sub-contracting signature certifies th°e'fiollowing:j,I certify that in the performance of the work for which this permit is issued,-I.shall employ persons s_6iii6ct to workman's compensa- tion laws of--California The applicant must ca f all repa"ir i pe tions:-- plete drawing on reverse_sid_e'. Signed .. - ' 9 � itle: 6�! Date• { FOR DEPARTMENT USE ONLY € w. Application Accepted by - �' ` °�`-� � A� Date �� _� Area J. Pit or Grout Inspection by 1 Date Final Inspection by - �� Date3— j , Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 >Nanteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Ehvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFO AMOUNT,DUE AMOUNT REMITTED CK - RECEIVED BY DATE PERM WNO." + EH 1324(REV.5/a 5Y ,`— - * `�� g�_�� • f EH 1426