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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'Telephone (209) 466-6781 i 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, [S 8 Job Address 8841 E. 14LOV. City SrkA/ Lot Size S Arnr-C PM Owner's Name Mig" W kA tock Address BE341 1W1 ?-(,2 - Phone ContractorSO - Address License No. Phone 46 fo' 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 : Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' ] ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _-._ Approlx_Depth-._❑ Eastern--I Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 bepth ' Filler Material.(Below-50'). .---- -- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ■ DESTRUCTION ❑ (No septic system permitted if public sewer is N t available within 200 feet.) S Installation will serve: Residence-X- Commercial— Other) Number of living units:,_� Number of bedrooms ._( I Character of soil to a depth of 3 feet-- Water table depth SEPTIC TANK ❑t Type/Mfg Capacity No- Compartments PKG. TREATMENT PLT. ❑1 r Method of Disposal .�,. ..y. Distance to nearest: Well Foundation "' Property Line r LEACHING LINE ,0 -No. & Length of lines- Ii2�i _ Total length/size FILTER BED ❑ aDistance to nearest. ,, Well`I5/ I Foundation ZO Property Line--*Z 0 e j SEEPAGE PITS 1� Depth ASSize 316' Number � } SUMPS ❑ }Distance to nearest: Well ACID{-�-Foundation -,ZQ'Property Line- DISPOSAL rie`DISPOSAL PONDS ❑ 1 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. .f - Home owner orFlicensed 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 fo workmari'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 Cali ornia." I Thea applicant must call for all-re uired pp q inspections. Complete drawing on reverse side. 1 F - Signed Ri{Title: ,'1# Date: s FOR DEPARTMENT USE ONLY ¢ . a_ Applicatrone Accepted by Date Area- ,Pit r•Grout Inspection by F Date ' s Final Inspe YU •bction by (3. Date Additional Comments: Sfic 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E."Haielion Ave., P.O.�Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH,CK 4 RECEIVED BY DATE PERMIT'NO. I EH13-24(REV.1 i h 5) EH 1428 - 1 ,