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;. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , _ 1601 E. HAZE I,ON,,AVE., STOCKTON, CA �''�Telephone'(209) 466-6781 A R R 2 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTAL HEALTHFERWT/SERy�� - Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. � plication 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 City of Size PM i 3l Owner's Name AAddr3ePD Duk � �1 1 9 phone 0 - ocr`o�w.�.tio q � Contractor u\M Address-pa se No. 1171 Phone TYPE OF WELL/PUMP: NEW WELL ❑ I a.—WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ge i SYSTEM REPAIR ❑ OTHER ❑ X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TENDED 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 Ll Irrigation _ .. —Approx. Depth Cl stern' Surface Seal Installed by Repair Work Done Lf . Type of Pump=. H.P. _- State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 I-f ' Depth _ Q;,Filler Material Melow 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 Commercial_ Other 'Number of living units: Number of bedrooms 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: Wei IF Foundation Property Line LEACHING LAVE ❑ No. & Length of lines Total length/size FILTER BEDA ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I spared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulati sof the Joaquin Local Health District. Home owner o icensed agent' signature certifies the following: "I cern at in the performance of the work for which this permit is issued, I shall not employ any rson in such man er as to become subje t to w man' co nsation Is of California."Contractor's hiring or sub-contracting signature certifies th ollowing: "l certi h in the performan of oT r ht ' it is issued, I shall employ persons subject to workman's compensa- tion laws f Californi . The appli ant'mus or all r ui►ed in ctio ing on r verse side. ' 3he Signed i te: FOR DEPARTMENT USE ONLY Application Accepted by Date ,!�C��,�,y� Area Pit or Grout Inspection'b .�_ Date Final Inspection by �!'� �/ ��— Data ZQ 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 CK 4 RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.1/05) EH M29 A