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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/purnp and the Rules and Regulations of the San Joaquin Local Health District. Job Address 10,37 46" TIfLY ,� � City IVV Al 1, Lot Size � �f0© PM_ Owner's Name 144&ffZ7 19 Address X 17 Phone e-,7;7 Contractor's Name /�f�lc'PeSN 7 f d�.� License No. ? 1�"�qJ Phone '5ti—96 6 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPT}C TANK _ SEWER LINES DISPOSAL FLD, PROP. LINE —FOUNDATION AGRICULTURE WELL OTHER WELL�T PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C) ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout V ❑ 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 1� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2DO feet.) �( Installation will serve: Residence L Commercial_ Other I y Number of living units:_�/_ Number of bedrooms Character of soil to a depth of 3 feet: _r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity/Z 6413 No. Compartmdnts PKG. TREATMENT PLT. ❑ I r Method of Disposal �--aDistance-to nearest: Well lD d Foundation /a Property Line 1 LEACHING LINE ❑ No. & Length of lines ZZ )e,T.S— -_ Total length/size �Z FILTER BED V1 Distance to nearest: Well Foundation 10� Property Line _r — SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:—Well— --- Foundation—propetty-L-ine-- — W.. DISPOSAL PONDS ❑ 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 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 workman's compensa- tion laws of California." The applicant t call for all required inspections.. Complete drawing on revers�ide. �' f �f'/��"�c� Date: �_�� Signed X ��" Title: FOR DEPARTMENT USE ONLY �� f Application Accepted by Date 0 Area 1 3 Pit or Grout Inspection by r v Date Final Inspection by �,.?� �d`' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3511 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 1 CASH + EH 13-241REV.101631 u �� v EH 14-28 l