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APPLICATION FOR PERMIT �►' SAN JOAQUIN LOCAL HEALTH DISTRICT 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 g ki 77,40nJ y City SM-1Z Lot Size _71's'_X 11 PM ., cc Phone -��6 Owner's Name �� M6 s S E� Address --� rla-04-Al, L/z-C-lAAl All—'_' No.�Y4Y76—Phone Contractor F�-d j/p WEB� Address �+ TYPE OF WELL/PUMP: NEW WELL El REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER El 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 El Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. f Well Casing Type of Casing Specifications ❑ Domestic/Private El Gravel Pack ❑ Tracy yp Type of Grout ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ 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 Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALL 10 ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septiclable syst m emitted if public sewer is Installation will serve: Residence' Commercial_ Other Number of living units: _/__ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK El Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: 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 workman's compensation laws of California."Contractor's 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 applicant must call for all required inspect ns. Complete drawing on reverse-side. 11 Date: Signed )C Title: J r FOR DEPARTMENT USE ONLY �� fJ� Date Area Application Accepted by _ Pit or Grout Inspection by Date Final Inspecti n by CJS" Date Additional Comments: ° ❑ Stk 466-6781 ❑ Lodi 369 1 ED] Manteca -7104 ❑ Tra4 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 55!= CK RECEIVED BY DATE PERMIT NO. CASH / _7r TIL F + EH 13-24(REV. 95) EH 14-26