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y� APPLICATION FOR PERMIT „ SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRESI 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 9 41 City MI Lot Size PM Owner's Name U S Address 401141-4661- Id mor �21' Phone -83 20 Contractor fkCI Address S.-W S l'Jr'r6TICAW,. SlIg License No.4—%X-10 its Phone 'NS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ n n hSYSTEM REPAIR ❑ _,w OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER;LINES " ; DISPOSAL FLD. ' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca .Dia: of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing {Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t Type of Grout ❑ Irrigation t __ 4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done © Type of Pump^ r H.P. State Work Done I Well Destruction " Well Diameter t-Irr j Sealing Material {top 50') �t Depth r1-S6 Filler Material {Below 5071 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑_ DESTWCTIOARl0Vo septic system permitted if public sewer is W , ailable within'200 feet.) Installation will serve: Residence_ Commercial-,!. Other Number of living units: Number of bedrooms w Character of soil to a depth of 3 feet:"f?, f' Water table depth SEPTIC TANK ❑ Type/MfgYCapacity No. Compartments PKG. TREATMENT PLT. Ll4, , i I Method of Disposal t' Distance to Pea est: Well Foundation Property Line R LEACHING LINE ❑ No. & Length of lines I" Total length/size FILTER BED : ❑ Distance to nearest: $ Well Foundation I Property Line E SEEPAGE PITS ❑ Depth Size Number, I SUMPS t ❑ Distance to nearest: Well Foundation i Property Linei 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 ar 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:'9 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. a The applicant.must call for all requireq inspections. Complete drawing on reverse side. j Signed r Title: 'Date: a FOR DEPARTMENT USE ONLY ti (� Application Accepted by Date% - Z�J Are Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy b ' t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201PEE { INFO AMOUNT.DUE �� AMOUNT-REMITTED,: ' 'CASH RECEIVED BY DATE CPEE/RMIT NO. EM 13-241REV.i/en) p l �"'3'$gyp p(p 74// EH W28