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L � APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781- PERMIT EXPIRES VYEAR 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin i Local Health District. Job Address Al9 ,City S 4i"�2f ._ Lot Size PM Owner's Name Ey� �Da rAddress ` �' E Phone Contractor Address Nr kr5/- License No. Phone TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT F1 'DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLO. PROP. LINE FOUNDATION AGRICULTURE WELL -ft'07)iER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STOUCTION�,SPECIFICATIONS 1 i ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other _❑ Delta Depth of Grout Seal *- Type of Grout _-- I I Irrigation ..Approx.Depth 1 1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth i Filler Material )Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted it public sewer is i vailable within 200 feet.) i = -Installation will serve: Residence_ Commercial Other Number of living units: j Number of bedrooms 4. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type Mfg Capacity No. Compartments PKG._TREATMENT PLT. El t Method of Disposal F c ! Distance to nearest: Well Foundation Property Line � f... E LEACHING LINE ❑ No. & Length of lines Total length/-size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L-], Distance to nearest: Well Foundation Property Line DISPOSAL_ PONDS ❑` 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. I{ 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 k employ any person in such manner as to become subject to workman's compensation laws of California."'Contractors hiring or sub-contracting signature !I 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 app70C-� t,�,callll for all jrequired "�spQections. Complete drawing on reverse side. Signed • AJ " _ Title: ©� �' Date: FOR DEPARTMENT USE ONLY Application Accepted by Date `^' O Area �n Pit or Grout Inspection by / Date Final Inspecti(on,by /;a� �"— +�� Date Tel Additional Comments: ❑ Stk 466-6781 D Lodi 369-3621' ❑ Manteca 823-7104 ❑ f racy ..839L6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601,'E.-Hazalton.Ave., P.O: Boz 2009, Stk., CA 01 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. R INFO rS7 ,1�' .�// yr, fes).,_` C,� + EH t3-24{REV.1/n 51 C! Up EH 1628