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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 .9 S / b �,/ � \ / 4) 1 Y City c^ F C r'd Lot Size PIN Owner's NameMA1T 1 N ��4J K%N 6-Address -S I r1 N �/� ! C N Phone -7 Contractor A 0» A/ Zoti ddress-2 1.1O MVV/1A-d V X e,/ � License Nord Phone TYPE OF WELL/PUMP: NEW WELL _ WEL RE��A /Z,y1ENT El DESTRUCTION El PUMP INSTALLATION° �'i5n�e'6-S YS i E: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 a Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications Public Other ❑ Delta Depth of Grout Seal Type of Grout = Irrigation ---Approx. Deep^th ` Easter S rface Seal Installed by Repair Work Done Type of Pump.�7 State Work Don Well Destruction Well Diameter Sealing Material (top 50') 3 Depth Filler Material (Below 501 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 ✓� i Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Q Method of Disposal / Distance to nearest: Well Foundation Property Line 6 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 7 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 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 in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- rion laws of California." -he applicant must call for all required inspections. Complete drawing on reverse side. Signed �` 2'� Title: Date: 12 e-- f5- FOR DEPARTMENT USE ONLY rn -� Application Accepted by Date Area v ?it or Grout Inspection by Date Final Inspection by / - -/ moi?. Date Aaditional Comments: Stk 466-6781 = Lodi 369-3621 = Manteca 323-7104 = Tracv 835-6385 .Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95201 FEE NEO AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. EH1326/REV. i EH 114.26 r