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t /} _ 1 APPLICATION FOR PERMIT , SAN JOAQUIN-LOCAL HEALTH DISTRICT t B 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 ty4,,,,�ju n �� PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Q r- rYfle✓ }+� (Complete in Triplicate) -�iJ1. 4 a. Application is hereby made to the San Joaquin Loral Health District for a permit to construct and/or install the work herein described. This applic�tion is I 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 City" Lot Size�U 6 X S2 7 PM i Owner's Name �� ft'�y Address Phone i Contractor Address License No. phone_ TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © HER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO AUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other Cl to Depth of Grout Seal Type of Grout _ I I Irrigation ,-Approx, De { I Eastern Surface Seal Installed bye Repair Work Done ❑ Type of Pu H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50'i Depth _aw I Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION*(-) REPAIR/ADDfTION I I DESTRUCTION (No,septic system permitted if public sewer is i available within 200 feet.] Installation will serve: Residence—, Commercial— Other'- Number ther'Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG: TREATMENT PLT. ❑ s Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or s issued, I shall employ persons subject te sub-contracting sign certifies the following:"I certify that-in the performance of the work for which this permit is workman's eompaturatur tion laws of California." Tire applicant m >m9c911 for al required inspections. Complete drawing on reverse side. X Signed X Title: Date: FOR DEPARTMENT.USE ONLY i Application Accepted by Date .Area i c Pit or Grout Inspection bAl r Date Final Inspection by Date Additional Comment . P/L / ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ M teca 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 INFO +� CASH RECEIVED tit DATE PERMIT'NO. + EH 13-24(REV.tix5) ",�C",()� zv �5S -mow EH 14-28 J CJ