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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CA 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. Job Address ' 94001 R6City Lot Size PM Owner's Name Ca Address ZA Phone Contractor del� -�GL,d2 Address 1_Os /fes,'/i��a License No.��Phone -- _ � TYPE OF WELLlPUMP: NEW VilELL.,❑ ��:,: WELL-REPLA�CEMENT-❑:, . DESTRUCTION'❑—'w"""�""'"�"-""'""'"'°"""` - — - - - - PUMP INSTALLATION'❑, "-"-`,"'- -""""SYSTEM`REPAIR'❑"""- OTFiER;O" --""^�-V�^•^ " 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 (`l Public (7 Other Cl Delta Depth-of Grout Seal Type of Grout I I Irrigation --Approxi Depth I Eastern Surface Seal installed by Repair Work Done (2 Type of Pump H.P. State Wo1rk Done mm Well Destruction ❑ Weil Diameter Sealing h/iaterialVltop_51]'1_: � Depth s Filler Material lBelow, 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I~1 INo septic system permitted if public sewer is '/ available within 200 feet.) �. Installation.will serve: Residence i« Commercial_ Other - Number of living units: Number of bedrooms 7 Character of soil to a depth of 3 feet: ADO 8 CE Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments O V PKG. TREATMENT PLT. ❑ '> Method of Disposal Distance to nearest: Well Foundation 1-=f Property Line LEACHING LINE ;-N No. & Length of lines /77 ,/ T Total length/size FILTER BED ❑ Distance to nearest: Well /Gooundation Property Line SEEPAGE PITS I 1 Depth Size } Number SUMPS D Distance to nears t: Well iFoundation 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 Di"strict. 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(tiring 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." 1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed.x s Title: oft.-04 Date:lQ'"' V-�! F[DEPARTMENT USE ONLY he / r Application Accepted by Data l� Area 2-` 6 Pit or Grout Inspection by Hate Final Inspection by s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621-0 Manteca--823-7104—❑Tracy--835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEERMIT'NO. �. +.EH14.241REV.1/n51 7V EH 14"2e I