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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT `] 1601 E. HAZELTON AVE., STOCKTON, CA 6 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 7 f K -Cit M 4-A�u� Lot ize _ �� L PM Job Address Y -Owner's-Name-<[f�h �011 h ,Address �i"V1t"P/ - T Phone Contractor _ 1( Address { License No.X2 STT a-Phone I -y s TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDAT16N 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 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications m Public Cl Other t, n Delta Depth of Grout Seal Type of Grout _ I E Irrigation Approx. Depth °I!I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump r H.P. State Work Done_ } Well Destruction ❑ Well Diameter Sealing Material (top 50') # Depth I Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is i lr '% available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other c w. i Number of living units: Nurnber of bedrooms 41 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ �4 Method of Disposal Distance to nearest: Well Foundation ' Property Line LEACHING LINE ,No. 13< Length of lines ��Q Total length/size- t FILTER BED ❑ Distance to nearest: Well y` Foundation ��, Property Line iio ; SEEPAGE PITS I I Depth Site r Number v ' SU PS L] Distance to neare*W Well Fol1 indation Property Line 1,,, DISPOSAL PONDS} ❑ '= f hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin codnty.ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. s ; 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 mannef as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cartifies'the fotlowing: "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." ` ' I t f re� ed Ceplicanm 'The ap - ainspections mpiete-drawing on reverse side. Signed'X 't•r�'l - Title: 4Q_112,Ak Date: 4C7t J l f I _FOR DEPARTIVI ENT USE ONLY t Application Accepted by F f Date -/7 Area / t Pit or Grout Inspection by Date _ Final Inspection by Date _17- / Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r ! . FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ♦ EH13-24rREV.tinsi y;