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A", 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 A6 Zpd6P= City Lot Size __ _ PM — Owner's Name { hll�VS/r � Address —moi Phone _ Contractor 04�I �f�LL�tP Address License.No..Jle Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION Cl 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 G Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private Ll Gravel Pack ❑ Tracy, Type of Casing Specifications f"1 Public CI Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done C- Type of Pump H.P. State Work Done Well Destruction C Well Diameter Sealing Material ftop 50'1 _.. Depth Filler Material Melow 501 TYPE OF,SEPTIC WORK: NEW INSTALLATIONX REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public solwer is available within 200 feet.) Insiallation will serve: Residence Commercial Other Number of living*units: 'L Number of bedrooms Character of soil to a depth of 3 feet: Water tAble depth SEPTIC TANK ❑ Type/Mfg 1' _ capacity -No. Compartments PKG. TREATMENT PLT.D �`T " s Method of Disposal Distance to nearest: Well C9O Foundation r Property Line LEACHING LINE _ No. & Length of fines __ Total l-e^ngthisize �r��-F-�__ FILTER BED 171 Distance to nearest: We� Foundation.02 � Property Line�L_! t I SEEPAGE PITS I Depth Size__-_ - Number SUMS L_. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 17 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. Homeowner 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." Contractors 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 California." The applicant must call fall r red inspections. Complete-diawing on reverse side. .-dam Signed f ✓ Title: Date: % FOR DEPARTMENT USE ONLY Application Accepted by _ Date __ Area -2 l�j Pit or Grout Inspection by _ Date Final Inspection by Additional Comments: __— ❑ Stk: 466.6781 ❑ Lodi 369.3621 D Manteca 823.7104 ❑ Tracy 835-6385 �p�► Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y C4 INFO, AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. . ERt3-241REV.iix5i EH 14-29