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4 : APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA fTelephone 12091 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 andlor 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, N Job Address Z 5 a3 1_aY r �I X1}`1 City- 5!%Zti%=ail Lot Size PM Owner's Name </_ m Address _!�77 570 3 /i i L� ,+„�+�_- Phone 6s —3I Contractor,. p2* Address l3�/%IMwAfrl5A License No.�70 r_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - x PUMP INSTALLATION- --SYSTEM-REPAIR 0 ,.z --OTHER-LI 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 _8-Open-Bottom- 0 Manteca: --Dia.-of WeILEkcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack t ❑ Tracy Type of Casing Specifications 1.1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout } I f Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by _ r Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 50') Depth I Filler Material (Below 50') �! TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is _ - r 1 available within 200 feet.) Installation will serve: Residence_ (Commercial_ Other h Number of living units: Number of bedrooms n 5 Character of soil to a depth of 3 feet: t4 y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1/`r PKG. TREATMENT PLT. ❑ - Method of Disposal ti Distance to nearest: Well Foundation Proper y Line-', r LEACHING LINE ❑ No. & Length of lines Total length/size f r FILTER BED ❑ Distance to nearest: Well f=oundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line rr DISPOSAL PONDS ❑ L 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 G 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 signatur---� 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.", t The applicant must call for all required inspections. Complete drawing on reverse side. QQ Signed X r TitlDate: QR DEPARTIIE USE ONLY s Application Accepted by Date�/ Area ly\ � Pit or Grout Inspection by Date final Inspection�blrt date f t / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEECK INFO AMOUNT DUE AMOUNT REMIT-TED 7, RECEIVED BY / DATE TPIERMIT NO. i.EH13-24(REV.iiK5) EH 14-211