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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CASCMNED 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 Sari 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 4Rv City Lot Size PM Owner's Name % jOROYNddress At_ C:�'/r'/�, Phone Contractor .S S ddress 9462::2 NUZ!2 (� .�f�„License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,V SYSTEM REPAIR ❑ OTHER ❑ 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 1-1 Public n Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation _--Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ARV Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION I ) INo septic system permitted if public sewer is available 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance fo nearest.”"--Well-F-- Foundation----_ -- Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑` Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11:1' Depth-:< . _Size _ Number SUMPS ❑ Distance to nerest: Well Foundation Property Line ' DISPOSAL PONOS ❑ I hereby certify that t have pr6pared1J iiapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaq=4n ;cal`Wealth Di§trict. Home owner or licensed age6t'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 minner as to become subjectto wor ,-compensation laws of California.",Contractor's hiring or sub-contracting signature certifies the following: "I certi�y that in the performance of thew rk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." l i The applicant f all equir ns ons. Complete awing on-reverse side. a Signed Tit ld' N 1 Date: FOR DE`s PAR ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date[ '/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 '0--Manteca '8217i64\\ `0 Tracy a3-5&385- A.pplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �.EH 13-21(REV. /n 5) EH 11-28