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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL i ON AVE., STOCKTON, CA } Telephone (209) 466-6781 PERMIT EXPIRES V YEAR FROM DATE ISSUED k, (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 a 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 1 Local Health District. 185$3 E Muni o Ave. City StpQkt-on 'Lot Size, 7141 0 PM Job Address t Address Phone 462- Owner's Name RMS 'AEdress Contractor Martin & $s1�ZY License No.3fO-851 Phone TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT C1 DESTRUCTION ❑ i PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ 23-51 ILI DISTANCE TO NEAREST: SEPTIC TANK 11 O 1*= SEWER LINES 1101 DISPOSAL FLD. 11 + PROP. LINE FOUNDATION 751 AGRICULTURE WELL NOrie OTHER WELL NOIR PUTS/SUMPS ane INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 5�8 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial t Stell Type of Casing Specifications [N Domestic/Private X Gravel Pack ❑ Tracy YP g 50 Type of Grout Bentonte Y. I n Public Cl Other I I ❑ Delta Depth of Grout Seal YP- I i I Irrigation __Approz Depth l•l Eastern- - -Surface-Seal installed-by----- - subm State Work Done ' Repair Work Dane ❑ Type of Pump H P f }' Sealin Material (top 50') QWell Destruction ElWeil Diameter 9 'T, Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I.1 DESTRUCTION I.I (Noseptic system m permitted if public sewer is avaInstallation will serve Residence_ Commercial Other r zi Number of living units: Number of bedrooms 1Water table depth Character of soil to a depth of 3'feet: a SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments" ( `� PKG. TREATMENT PLT. ❑ Method of Disposal r = Distance to nearest: Well 'Foundation Property Line t LEACHING LINE ❑ No. & Length of lines -o'"Total length/size i FILTER BED ❑ Distance tck nearest: Well Foundat'i n Property Line 'Ion+. . `Iti I __-1 I SEEPAGE PITS I'1�IDe� th . t' Size,-' .J °Number t P _ r��`n SUMPS ❑ Distance to n arestj:.r"'Well t"��- Founda`tion�" k Property Line f DISPOSAL PONDS ❑ I hereby certify that I have prepared this`applicatioh and that the work will be done in accordance with San Joaquin county ordinances, state laws, and l rules and regulations of the San Joaquin Local Health DI1trict. % 30, ' Home owner or licensed agent's signature certifies the following: "I certify that in the performanceofthe work for which this permit is issued, 1 shalt not ' employ any person in such manner as to become subject to workman's cortipansation 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- I tion laws of California." The applican st call for all re pection omplete draw g on r arse side.. Signed K Date: FOR DEPARTMENT USE ONLY r 11 Application Accepted by —. 1pr s Date ��' - Area Date, �/ Final Inspection by Date Pit or Grout Inspection,by r w E Additional Comments: ' ❑ Stk 466-6781 i[3Lodi 369=3621 ❑ Manteca 823-7104-1 ❑ Tracy 835-M ' 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FSE ' AMOUNT DUE -AMOUNT REMITTED RECEIVED By DATE PERMIT NO. +.EH 1324(REV.i EH 14-26