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P Ju Naves 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. JobAddress ^ � - City• Lot PM s. Owner's Name00, Address " C Phone ` YOL Contractor's Nam License No.4;z Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATIGN SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A5 ZE DISPOSAL FLD. PROP. LINE 50 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 6"0-P—en-8ottom ❑ Manteca "Dia. of Well Excavation f ft7 Dia. of Well Casing E3" o�/Private ❑ Gravel Pack ❑ Tracy i Type of Casingcifications QA ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Typ out ❑ Irrigation ---Approx. Depth ❑ stern urface Seal Installed by Repair Work Done ❑ Type of Pump MH.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 501 Depth f Filler Material (Below 501 TYPE OF SEPTIC WORK:—NEW.INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is + available within 200 feet.) Installation-1-ill serve: Residence Commercial_ Other i �•� Number of living units:' -Number of bedrooms ' 4 Character of soil to 13-depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg f Capacity No. Compartments {.;,PrKG. TREATMENT PLT. ❑ Method of Disposal 4 . Distance to nearest',-aWeII_ --- g Foundation Property Line LEACHING LINE ❑ No. & Length of lines. .,Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ID Dista Distanto nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ f j 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.cerdfy.that.in thle 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." j r The applicant m all r all required inspections. Complet' r ing on reverse side. ! Signed Title: Date: J � A J POR DEPARTMENT USE ONLY np.� ( Application Accepted by r�N / - Data 2 "� u s a Pit or Grout Inspection by 'Date Final Inspection by ate 5 Additional Comments: t❑-SStk,,:466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 ` Applicant I-Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NFEEFO AMOUNT pUE AMOUNT REMITTED w RECEIVED BY' PATE PERMIT N0. + EH 13-24(REV.141831 , EH 1126