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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 AddressSY149" CityS!/� Lot Size G — PM 'Owner's Name /gip s' /'fie 4r-h-A11V Address M Phone Contractor's Name IGr1�R91 162 �cflFws- .License No. �.��"'�� - Phone 4� ,", - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ `r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' , ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence I,/Commercial_ Other Number of living units: Number of bedrooms_ 3 oil Character of soil to a depth of 3 feet: [4*4—V- - +"%ater-tablePdepthr---- a SEPTIC TANK ❑ Type/Mfg �� Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line'— LEACHING ineLEACHING LINE Cly No. & Length of lines Total length/size ` �Jl FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS �JDepth j Is- Size 66 Number i SUMPS ❑ Distance to nearest: Well /,642 Foundation X O Property Line v : DISPOSAL PONDS ❑ hereby certify,.that I have prepared this applicat ioh 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 followirig:"I certify that in the performance of the work for which this permit issued, I shall employ persons subject to workman's cdmpensa- tion laws of California." The applicant ust call for all required ' sped omplate drawing on re-Ver-se- ide." Signed Title: Date: DEPARTM U � ONLY, Application Accepted by r Date - Area{' ' ,p fj �, Pit or Grout Inspection by U"�l "L�y "�-Date Final Inspection by Date Additional Comm nts: ❑ Stk-466-6781'- ❑-Lodi-369-3621 O Manteca-823-7104 ILITracy 8315-M -+--� 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 1324{REV.10163E % 'U /.7 �0 q6 EH 1426 /�