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APPLICATION FOR PERMIT SAKI 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 wy- 9 City Lot Size 3 M C mr9AJ1�� Owner's Name LE [ /_19j�� Rc� �� _ Address �`1 �T li ccyy�� ,, �yPhone Contractor �f ddress-sem 2Rjzl _ License No. �.XlX_�dJ Phone a/y�" C1 TYPE OF WELL/PUMP: NEW 4VELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM_REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.., PROP. LINE FOUNDATION QAGRICULTURE WELL OTHER WELLPITS/SUMPS �O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJIIndustrial L1 Open Bottom LJManteca Dia. of Well Excavation Dia- of Well Casing �/8 (j+lpornestic/Private lk-Gravel Pack ❑ Tracy Type of Casing Specifications n El Public El Other ❑ Delta Depth of Grout Seal 5c, Type of Grout LJ FPJ m oT ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. . ? Stale Wofk1Done_ �l Well Destruction ❑ Well Diamelgr r-�- Sealing Material (top 501 -�eiqn Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other y Number of living units: Number of bedrooms V— Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments e PKG. TREATMENT PLT. ❑ Method of Disposal v Distance to nearest: Well Ibundation Property Line j--. LEACHING LINE ❑, No. & Length of lines - _ Total length/size FILTER BED ❑ Distance to nearest: Well )FoUhdation Property Line ` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 riles and regulations of the San Joaquin Local Health District. 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 n 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 call for all required inspections. Complet awing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY c�7 Application Accepted by Date Area Pit or Grout Inspection by ate ��w Final Inspection by Additional Comments: —_ ❑ Stk 466-6781 ❑ Lodi 369-3621 3<Manteca 8237104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Hea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C C-ASWRECEIVED BY DATE PEAMIT NO. a EH 13-24(REV.//H5) 10�, ^�S O !.�`� EH 1448 1 17