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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL-,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I.YEAR FROM DATE ISSUED F 4 I(Golnplete 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 J Local Health District. w r 91 res-f- c� F ' , Job Address , + i City Y •.Lot Size ' PM Owner's Name eAd a afeSWO Address +(4=- Phone 36!L_SdWd Contractor's Name �'. License No. Phone f 'a 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 -FOUNDATION AGRICULTURE WELL OTHER WELL-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑1'Fr��„ _.lrype,of Casing specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 11� Sealing Material.(top 501 } Depth 1 Filler Material (Below 501 —� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic tystem permitted if public sewer is availableu�thin 200 feet.) Installation will serve: Res'dence! Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Waltable depth SEPTIC TANK Typa:Mfg Capacity'- " ` No. Compartments PKG. TREATMENT PLT. ❑ p I f Method of Disposal Distance to net: Well Foundation =� Property Line LEACHING LINE ❑ No. & Length of lines oral length/size FILTER BED i� Distance to nearest: Well foundation Property Li#e i SEEPAGE PITS � Depth ? Size Number r _ l SUMPS = :❑ Distance to nearest: Well Foundation Property Line -7� , DISPOSAL PONDS ❑ c s T ,.. ' - r 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 I" rules and regulations of the San Joaquin Local Health I District, r f. Home owner or licensed agent's signature certifies the following: "I certify that in the performanc eof the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's p6gipensation laws of California."-Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performenceiof the i�r�ric'forvXch this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica Fall req u' d inspections. Co drawing on reverse side. Signed X Title: �' a... Date: FOR DEPAR MENT USE ONLY Application Accepted by Date Area i it r Grout Inspection by� '50-D to —� nal Inspection by Date Additional Comments: F ', ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE FERMI-r NO. wb SSS- i np + EH13-24 lREV.10183) EH 1x28