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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone 1209) 466-6781 I F PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) k 1 Application is hereby made to the San Uoaquin Local Health District for a permit to construct and/or install the work herein described. This application is `k 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. r Job Address 1.3 kD 6 +. i p1144 &City M(21 fi{_,G•&Lot Size PM Owner's Name `K O Address Phone I ContractorL FA j,Yfe ; Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑r-, 4 WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION .❑ i �- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLO: PROP. LINE Fr FOUNDATION " rAGRiCULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE-. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial : 0 Open Bottom ❑ Manteca Dia. of-Well Excavation Dia. of Well Casing H_ Domestic/Private LI Gravel Pack Irl Tracy Type of Casing Specifications f'l Public l_l Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —_Approxi Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of-Pump -H.P. — State Work-Done Well Destruction ❑ Well Diameter Sealing Material (top 50') # Depth Filler Material (Below '1 j TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I l iNo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: —A— Number of bedrooms_ �Y. I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑"Type%Mfg Capacity f No. Compartments PKG, TREATMENT PLT. 0,1 ,. ! Method of Disposal E _ ! Distance to nearest: Well Foundation-- > 'Property Line LEACHING LINE V."_No. & Length of lines Tot l length/size $� FILTER BED ❑` Distance to nearest: Well� sVFoundation 35� Property Line , f w. SEEPAGE PITS l I. Depth t Size Number SUMPS 0. Distance to nearest: Well ` Foundation'.. f Property Line DISPOSAL PONDS. ❑" I 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-taws of California." Contractors hiring or sub-contracting signature certifies the following: "I cartify that in the performance of the work far whi h this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t 3s The applicant must call for all required inspections.`Complete drawing on reverse'side. Signed X—. . y�N�.- ..,.�� `Title:''' Date: i FOR-DEPARTMENT USE ONLY Application Accepted by _ i Date �� Area t ' o 0 '. [ r y Pit or Grout Inspection by Date Final Inspection by Date. Additional Comments: t I J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 i� Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601,.E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEEe INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. .w I + EH 1324(REV.tins) D t —EH_14,26.