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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. t �1..J r Job Address "�1 ! City Lot Size�. PM 4AJ" Owner's Name� ''r Address 10 OLI hona 3 ' Contract r C!A"1 Address! J7 I h6 License fro. Z(.a Phone �� S,16 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER`❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI-D. PROP: LINE -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Puhlic ❑ Other n Delta Depth of Grout Seal Type of Grout. _ 11•Irrigation _Approx. Depth l I Eastern Surface Seal Installed by _ 'Repair Work Done ❑ Type of Pump H,P. State Work Done _ . Well Destruction ❑ We11'Diameter Sealing Material (top 501 s Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW'INSTALLATION 1. REPAIR/ADDITION l-1 DESTRUCTION l 1 (No septic system permitted if public sewer is ,-� available within 200 feet.) *\ Installation will serve: Residence( Commercial_ Other Number of living units: _ Number of bedroorn �\ Character of soil to a depth of 3 feet: f Water tableydepth' ,f SEPTIC TANK U?-Type/Mfg in_t4. "A yy16 06 Nil ComparCme'rits PKG. TREATMENT PLT. ❑ A r fMethod•ofa-Disposal Distance to�neare /`. Well Foundation PrtyLine� L LEACHING LINE Pr_NO.-.&'Length. IV <— *' f' Total`I gth/size 74f X FILTER BED Distance to nearestr Weil',, Foundation— Property Line4 I SEEPAGE PITS depth Si e �-' Number SUMPS Ll Distance to nearest: Well /' Found`Mion_-- �__ Pr`operty Line v Y 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 regulatioris,of the San Joaquin,Local,Health District. " Home owner or licensed agent's signature'cer ifies 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;tdbedome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: 'Tcartify 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." Thome applicant st call fo I-re fired inspections. Complete,dfawing on reverse sl �I r Signed X Title: �f—e_ Date: I FOR DEPARTMENT USE ONLY / Q D Area , Application Accepted by 2. /-�i Date ✓ _ 6or Grout Inspection by Dat -� -rD Final Inspection by t Additional Comments: l ' ❑ 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 INFO FEE $�AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT'NO. + EH 1 -241REV.1/r+51 { EH 144-28