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S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w (Complete in Triplicate) , Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address City r Lot Size PM AV t x Owners Name Address'-2:7w W, 2 4449, Phone Contractor Ad$fMLCCL&- Address — License No.� :S-720 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER I 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 JlL Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done [y Type of Pumpd Ul� H.P. �`� Stat/Work Do Well Destruction ❑ Well Diameter Sealing Material (top S0') ��+ i , Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is. ee=• tfi available within'200 feet.) Installation will serve: Residence— Gommercial3 Oet; Number of living units: Number of bedrooms Character of soil to a depth of 3 fee#: Water table depth SEPTIC TANK ❑ T �-"-,- .z .-�_C_._ s 2. o' .me ype/IVlfg'�""'"L-"' `� Capacity No. Gompartments PKG. TREATMENT PLT. ❑ . y:r; "iP o -'Method of Disposal Distance to nearest: Well Foundation— � Property Line ~ LEACHING LINE ❑ ' No. & Length of lines a Total length/size ' FILTER BED ❑ Distance to nearest: Well Fouhdat""ions Property Line ' SEEPAGE PITS 1:1Depth Size Number r f SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in'6c66rdance 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 he 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." ` The applicant must call for all required inspections: Complete drawing on r9welse side. Signed Title: Date: 7 DEPARTMENT USE ONLY ry 4 /! Date ,9 �I:1 e Area Application Accepted by / Pit or Grout Inspection by Date Final Inspection by Date% Additional Comments: ❑ Stk 466-67$1 ❑ 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 AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE- PERMIT'NO, H INFO + EH 13-241REV,1/a 51 - 3S EH 14.28