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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 .. .. [/-�?_� !V a,6W n City ,�.+ir Lot Size PM Owner's Name FI /�E Address Phone ' Contractor C �P/YI.�iIJ� St/5 Address 4 - .4Y.! /e 411 License No. o/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONXP,4JAiL9C,&aYSTEM 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 j Dia. of Well Casing 30 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing / Specifications f r ❑ Public ❑ Other (a Delta Depth of Grout Seal ' Type of Grout I I Ifrigation _Approx, Depth I I Eastern 'S rface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 7 State Work Done �liCiL Well Destruction ❑ Well Diameter Sealing Material (top 50') 4` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION I 1 INo 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 of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ i —'DistarscL� to neafes"f`"—'Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FJLTETi '13-1N tance to nearest: Well" Foundation Property Line 5 1 SEEPAGE PITS k i I Depth Size f Number SUMPS ) Cl Di�'tance-to-nearest Well f Foundation Property Line q DISPOSAL-PONDS ❑ ice- t I hereby certify;that I have prepared,this appiication and that the W6 k will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local` 40th District. � Home owner or licensed agent's signaturefcertifies the following:,, .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 becortie stibjecirto workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "i certify that-i"he.performalkce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." f The appfica pr I requi ions. Complete drawing onr arse side. j q Signed X TiNe: bate: / U r'n i , f FOR DEPARTMENT USE ONLY t -1' -2/6 r Application Accepted by Q l _ _ Date AArea Pit or Grout Inspection by Date Final Inspection by Date 4_ 8`S/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 : 1 FEE INFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT-NO. r.EH13-24(REV.r/rr51 EH 14-28