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,4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE'ISSUED (Complete in Triplicate) Application is hereby made tp 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. /R,nS � — 7 Job Address 0' " City of Size 15C PM Owner's Name Address - Phone Contractor gd:WddressM_1License No Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION dO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST;'SEPTICITANK ' SEWER LINES DISPOSAL FLD. PROP. LINE yFOUNDATION + 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 ❑ 6ave1.Pack i ❑ Tracy ' Type of Casing v Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout J� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material {Below 501 O TYPE OF SEPTIC WORK: NEW INSTALLATION 9 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,/ available within 200 feet.) Installation will serve: Residence Comme tial_ Other' T Number of living units: Number of bedroom's i Q� ` Character of soil to a depth of 3 feet: Water table depth O —`T SEPTIC TANK ❑ Type/Mfg 77 CapacityNo.,Compartments PKG. TREATMENT PLT. ❑ t° / r f Method of Dispo rn a� Distance to nearest: /Well J f/ Foundation a• �Froperty Line_ 5 LEACHING LINE ,W No. & Length of lines Total length/size, ZO FILTER SED ❑ Distance to nearest: Well Foundation A Property'LineAo EP4GE PIT- Depth ��..f *ize x-1 �`� .' Number ! U yyi S ❑ Distancefto nearest: Well Foundation Property Line ISPOSALI PO S ❑ 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,-)shall employ persons subject to workman's compensa- tion laws of California." The applicant mut for.all rere inspections. mplete,drawing o verse side. { ., I Signed Title:� /-��►® —� Dat@J/1 Xzl, A001 FOR DEPARTMENT USE ONLY n Application'Accepted by Date �� F-6 Ares Pit or Grout Inspection by Date Final Inspection by Date o Additional Comments: 3` f� /- ❑ Stk 466-6781 ❑ Lodi -3611 ❑ Manteca 823-7104. ❑ Tracy G f! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box , Stk CA 95201 ! FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +11-1 1324(REV.1/e 5) EH 14-25 � �� i .. s