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+w! APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED IComplete 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 — Lot Size ECJ rao PM Owner's Name. i Ile Address � e � Phone Contractor + J AddresS4� 114 -7-1 _ License No.�;k3 2--'711&Phone 41F74 1-7- TYPE -7TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public L1 Other F] Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth I Eastern Surface Seal Installed by" �' (� Repair Work Done ❑ Type of Pump H.P. State Work bone_ Well Destruction ❑ Well Diameter Sealing Material (top 501 s Depth Filler Material (Below 501NN, TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION OfTNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms.:— Character edrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines ` t Total length/size >i FILTER BED ❑ Distance to nearest: Well Foundation Property Line. SEEPAGE PITS I 1 Depth Site # Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` I hereby certify that l 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 and, 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, 1 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 !he f wing: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws alifo nia." 4 , The appy /n u c It for all required inspections. Complete drawing on reverse side. Signed TiNe:`,r� Date. FOR DEPARTMENT USE ONLY _ 1 Application Accepted by �` ;," "" '`3 ` Date - J Area Pit or Grout Inspe t' by Date Final Ipspection by Date a Additional Comments: "l' ` ❑ Stk 466-6781 Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 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 ASH RECEIVED BY DATE PERMIT'No. INFO �J + EH t3-241REv.i/H5) �� saG�J fQ-- EH 1426 - [/