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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 9 � MAXWweL4 1- td nio ao f Job Address q � / City � 1 �'i Lat Size �� PM Owner's Name SSS J N-e Y(l1 Address Phone Contractor Address License No. Phone s� TYPE OF WELL/PUMP: NEW WELL ❑ L REPLACEMENT ❑ DESTRUCTION ❑, PUMP INSTALLATION ❑ SYkIEM REPAIR OTHER JV �ew>� Naaic u.P DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE N ISPOSAL FLO. �` PROP. LINE' ; ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR TI SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca. Dia. ell Exca ion Dia. of Well Casing VID-omestic/Private C1 Gravel'Pack ❑ Tracy's T 'e of Casing Specifications f'1 Public F1 Other n Delta epth of Grout Seal Type of Grout i ].Irrigation --Approx. Depth t I Eastern Y Surface Seal Installed by Repair Work Done ❑ Type of Pump H State Done 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler�Nlateria1,1Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION I l DESTRUCTION (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence L.--l-commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Ah Water table depth 1-0 SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ - Distance to nearest: Well Foundation Property Line r SEEPAGE PITS t I Depth Y T Size _ Number t SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I r 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 `/ rules and regulations of the San Joaquin Local Health District. H6me 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons,subject to workmari's compensa- tion_taws of California." The applicant must call for all required inspections. Complete drawing on r ierse side. Signed X Title: Date: .,-- go, — .I A FOEPARTMENT USE ONLY ! Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b _ Dat 7 . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E FEE 1NOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE" PERMIT NO. r ♦.EH 13-24 IREV.1/x s! ��D � CASH EH 14-28