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II�� 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. f�/f AlJob Address ff /►y �f# (l � _-- City Lot Size PM Owner's Name9 � 4 0207 �s 4-W e6 Phone t1�',k Contractor AS tldr A' e� �� ss f�� —License IV g Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION We( S PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca t Dia. of Well Excavation Dia. of Well Casing a ❑ Domestic/Private ❑ Gravel Pack! © Tracy Type of Casing Specifications (l Public Cl Other fl Delta j Depth of Grout Seal Type of Grout _ A4 I Irrigation L _Apprax. Depth l I Eastern Surface Seal Installed by � Repair Work Done ❑ Type of Pump /fIH.P. State Work Don Well Destruction Well Dia eter!L_.Lq.._.-�f®�Sealing Mate�iai /top 50'1 �� ¢ Depth VO ZC 110 Filler Material ('Below'50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION it REPAIR/ADDITION l 1 DESTRUCTION(til INo septic system permitted 4 public sewer is A available within 200 feet.) installation will serve: Residence Commercial Other f Number of living units: Number of bedrooms 1 I 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 f Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size A :--FILTER BED — -- ❑• Distance-to*nearest: , Well - -Foundation ^^ - —Property'Line-- SEEPAGE PITS l I Depth Size Number i SUMPS D Distance toinearest: Well Foundation Property Line k DISPOSAL PONDS ❑ { 1 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 applican u �requons. Complete drawing on -4116side. s Signed X of Title: Date: F �r FOR DEPARTMENT USE NLY )] (� Application Accepted by Date Area C Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ' ❑ Stk 466-6787 ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE Q PERMIT-NO. + EM 13-24 1REV.t/N 51 �f I ,— O / D 4 A EH 14-28 i