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p APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin k Local Health District. Job Address City STI`K - Lot Size/014 A 'S/aD PM Owner's Name ,/4,f/Al Address s__,dl, `Phone I Contractor's Name S �� License No. 21 V "' 3 /3 Phone �' d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Ld INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ OpenBottoms-- '"EI-Manteca.----aF-=Dia:'af"We`ll Ezcevation Di*. of Well Casing J_ .wy ' ❑ Domestic/Private ❑_Gravel Pack-'El—Tracy"'- "" Type of'CA-sing "'" Specifications ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 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—r`Commercial_ Other 1j Number of living units: -.-/— Number of bedrooms 3 C f Character of soil to a depth of 3 feet: G y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No:Compartments PKG. TREATMENT PLT. ❑ Method of Disposal - Distance to nearest: Well Foundation Property Line �:.,r[n•,,,,,,,.....�....�- -...,-- —..,-+a•-..:.,.........e �,..-. -_._, ... mow..-.--.w�*--wwFa� �w.e. / dT� .:Total len h/size . �� LEACHING LINE GK`No. & Length of lines gt + FILTER BED ❑ Distance to nearest: Well 460 Foundation's �� " Property Line° SEEPAGE PITS 4 Depth Size a-Number f '.... SUMPS ❑ Distance to nearest: - `.'Well oeW Foundation_" r Property Line ' j DISPOSAL PONDS ❑ M y 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 shali•not employ any person in such manner as to become subject to workman's compensation laws of Cal'rfornia."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 applican call for all required ins ctions. Complete drawing on revvee'�r�./J`si!!,,f' /r Signed Title: Date ' FOR DEPARTMENT USE ONLY I !� Date I Application Accepted by 7pWArea , I Pit or Grout inspection by. `r r _ Date Final Inspection by f Date 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 AMOUNT DUE I AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT:'NO. INFO CASH y + EEH 13-24 H 1 /REV. 10183) t