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n 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. [� Job Address J %vk City >M��`G� Lot Size PM Owner's Name k0kKOM0/1Address � ___ Phone Contractdr l ''r Address. 100 )0 9f Atli -- License No. �S dZ Phone 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 y ,� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ___..Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') v`D TYPE OF'SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION [ l INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence Commercial Other Qil Number of living units: Number of bedrooms rvtQ Character of soil to a depth of 3 feet: °T�f Water table depth t 4 SEPTIC TANK ❑ Type/MfgCapacity '_...__.-. _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines ~ In TTolal length/size FILTER BED ❑ Distance to nearest: Welles Foundation �+�"' Property Line IQ SEEPAGE PITS I I Depth Size Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di;'trict. 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, I shall employ persons subject to workman's compensa- tion,15ws:of California." �,The.applicant must call for aii inspections. Complete drawing on reverse side.e. 114 GSigned X' requi d inTitle: _ A�J�1l Date: 8o �R pEP MENT USE ONLY .10 Application Accepted by Date ... Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 '❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE II INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. _ +.EH 53-24{REV.FlN51 117-0. Pf/)a/t+� .0(u EH 14-29 !!!