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'f APPLICATION FOR PERMIT ,i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in T(tplicate) 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. Q Job Address ��' ! -•� R lI�F/CLl� City fin/?A — Lot Size fS_-1y' 6 U PAA Owner's Name 16• W aA S/'/16167 2r,Al, Address Phone 44-- Contractor _ Ob Address 10 41+—a-+ License No.��Phone 4 '3'77,/ TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA_IR 171OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 1 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial 17 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Specifications EJ Domestic/Private ❑ Gravel Pack 15.Tracy Type of CasingF ❑ Public ❑ Other i ❑ Delta', Depth of Grout Seal Type of Grout ❑ Irrigation �Approx. Depth '9 Eastern Surface Seat Installed by Repair Work Done ❑ Type of PluMp,. _ H.P. ' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 . Depth Filler Material (Below 501) 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is i r 1 vailable within 200 feet.) Installation will serve: Residence— Commercial— Other ` '• �" Number of living units: Number of bedrooms r!s Character of soil to a depth of 3 feet: SEPTIC TAMC Ll Type/Mfg PtY Water table depth aci No. Compartments PKG. TREATMENT PLT. ❑ s '"° Method of Disposal Distan a to nearest: Fouridation Property Line LEACHING LINE ❑ No. &;Length of linese l Total length/size FILTER BED ❑ Distance to nearest:__ Weil Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 required inspections. mplete drawing on reverse side. Title:_�� `rte Signed Date:. FOR DEPARTMENT USE ONLY F QW Application Accepted by � Date Area Pit or Grout Inspection by Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy !.835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazeltoAve., P.O. Box 2009, Stk., CA 95201 r , FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO + EH 13-241REV.1/a 5/ Ds*-00 00%-ZS Pe dbw~1�O EH 1426 f/t�