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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. HAZEL T ON 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 � � City L0 Lot Size l �4C PM Owner's Ham/a11� Address ��yr, Phone � G� Contractor t9 Address 12,637` aelu0 19141 License No.&O 7�1_-Phone 3 T3 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 . I C>1 ❑ Industrial # ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gfavel Pack ❑ Tracy Type of Casing Specifications (•1 Public [ ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth t I Eastern. Surface Seal Installed by— Repair y Repair Work bone ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (stop 501 } I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION € I (No septic system permitted if public sewer is } available within 200 feet'l Installation will serve: Residence r Commercial_ Other �f Number of'living units: Number of beArooms Z� Character of soil to a depth of 3 feet: ^. Water table depth d SEPTIC TANK ❑ Type/Mfg CapaciiNo. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearest:----Well—'—--—Founlatior Property Line. I ,LEACHING LINE ❑ No. & Length of lines Total''iength/sie� FILTERI, ED ❑ Distance to nearest: Well Foundation F Property;Line I 1 SEEPAGE PITS l Depth Size * Number t A 1t j SUPS LlDistance to neare)t: Well I Foundation Property rL'ne � DISP05AL PONDS ❑ xf i ' 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-Diltrict.. Home ownerorlicensed 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 taws 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 emploV persons subject to workman's compensa- tion laws of California." I The applicantmustcall for all required inspections. Complete drawing on reverse side. Signed X I /1 Title: ©WA)CA Date: FOR DE ARTMEf1lT USE ONLY Application ccepted by �� Date �� Area r fjtt b)1 Grout Inspection by -. Date Final Inspection tfy Date $ Y Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 0 Manieca� 623-7104"--Cl`f Bcy 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 REMITTED CK RECEIVED BY DATE PERMIT*NO. INFO CASH ..EH 13-24 REV, is EH 1446 Z ! X, s