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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 ! 44K, City Lot Size PM LOwner's Name -32W Address �` f �- a�`-ff �� Phone 0 Contractor Address f License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Open Bottom E Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal TGrout—_ i ? ype of 1�J ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction C❑ Well Diameter Sealing Material (top 501 6 Depth Filler Material (Below 501 - N TYPE OF SEPTIC WORK: NEW INSTALLATION.Ii REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is S � available within 200 feet.) Installation will serve: Residence X— Commercial_ Other rn Number of living units; Number of bed ooms Character of soil to a depth of 3 feet:. ra Water table depth SEPTIC TANK ❑ T e/Mf C pa ry /tea No. Compartments Type/Mfg g -- Caci PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well j.' Foundation Property Line 6 LEACHING LINE ❑ No. rat Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Well Foundation Property Line {b SEEPAGE PITS Cl Depth +' Size 6 Dumber SUMPS ElDistance to nearest: Well 61920'07_ Foundation _., Property Line '34940 DISPOSAL PONDS ❑ y. 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 r rules and regulations of the San Joaquin Local Health District. e - 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 signature certifies the following: "f 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 for all required inspections. Complete drawing on reverse side. Signed ct.�, Title:. Date: R 3 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 30 K�b 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 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 MEV. //� EH 14-28 rr�a46