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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON 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. Job Address /037 City Lot Size ' ` 4d PM 922 Owner's Name nmc) kaoa Address tz-n1 - Phone dA & ytttit,2 _ o. 3 7_ 1Q1 Phone ` � Contractor's Name � _ TYPE OF WELL/PUMP: NEW WELL �'WELL REPLACEMENT ❑ DESTRUCTION ❑_ ' PUMP INSTALLATIO 1 / SYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLDD.�.��—f� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELC_4 L PITS/SUMPS INTENDED USE TYPE OF WELL PRO"AREA CONSTRUCTION SPECIFICAT I/ ❑ Indu 1 ❑ Open om anteca Dia. of Well Excavation Dia. of Well Casing mastic/Private ELAdaivel Pack ❑ Tracy Type of Casing I Specifications S El Public E3 Other ❑ Delta Depth of Grout Seal r e of Grout ❑ Irrigation ---Approx. De stern Surf ce Seal Installed by Al iC Repair Work Done ❑ Type of Pump H.P. 7 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') "- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION OT -DESTRUCTION ❑ (No septic system permitted if public sewer is x� available within 2b0 feet.) I Installation will serve: Residence_ Commercial_ Other j 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 E PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line -----�- LEACHING LINE ❑ No. & Length of lines ,Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property One DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dome 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."Contractoes 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 applica mu t cal r I re ins i s. Complete drawing one. Signed Title: '~ Date: FORD PARTMENT USE ONLY Application Accepted by Date ` '^ �� Area Pit or Grout Inspection by Date Final Inspection byT1� A Date 10 Additional Comments: 174(y -6",r,1t juv j ❑ Stk 466-6781 L] Lodi 3643621 ❑ 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 95261 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. +tiH 13-24(REY.101$3) Lt'9 af. EH 14-28