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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TriplicatO 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin ' Local Health District. Job Address �LZi,�_ City �� Lot Size PM { e J Owner's Name 1&r1 Address Phone Contractor's Name /t t 46 W&PY A License No: c2-65 F ;7, 5! '2'a� Phone v " TYPE OF WEL 'PUMP:.` NEW WELL ❑ WELL REPLACEMENT LJ -DESTRUCTION ❑ W ; PUMP INSTALLATION ❑ " SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS 7� j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler IVfaterial`(Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTIO5_�IAlable ptic system permitted if public sewer is within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms -� Character of soil to a depth of 3 feet: Water table depth !Y1 SEPTIC TANK ❑ Type/Mfg Capacity :No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE El :No. &Length of lines # I Total length/size FILTER BED ❑ Distance to neare t:"� Well- Foundation Property Line SEEPAGE PITS ❑ Dapth Size Number SUMPS ❑ Distance to nearest x Well Foundation. 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 workmari'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." The applicant must call for a I req 'red in ctions. Complete drawing on"rev.gr��sesidee.—. Signed Title: C �L�.� /1 Date: &-- 2 L Y3 A E E ONLY Application Accepted b Date Area 0 Pit or Grout Inspe by Datet _ Final Inspection by lww� a-R+ ' Date Additional Comments: ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE QPERMITNO.r + EH 13-24(REV.10183) Z O a-^� / 1�� a��-� Q3�f�� J EH 14-26