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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. - Job Address ''f 72Y Lot Size PM Cit 5 _ 4 ` f Owner's Nam �-Address".� �/Z Phone J Contr ddress � � fWV G[�L.� License No.-3,60sZ- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT. ❑ DE=STRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ;DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER`WELL PITS/SUMPS NDED USE YPE OF.WELL PROBLEM AREA CONSTR 5 ❑ Industrial ❑ Open o ❑ Manteca ta. of Well Excavation ": Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing t Specifications FI Public n Other Cl Delta out Seal., r Type of Grout . r — i I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installe � Repair Work Done Type of Pump H.P. /State Work o Well Destruction ❑ Well Diameter Sealing Material (top 50'1 / Depth Filler Material (Below 501/ TYPE OF SEPTIC-WORK: NEW INSTALLATION I 1 REPAIR/ADDITION E I DESTRUCTIONA INo septic system permitted if public sewer is rr available within 200 feet.) Y Installation will serve: Residence_ Commercial_ Other �} Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATME=NT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ! LEACHING LINE ❑ No. & Length of lines Total length/size 7 FILTER BED ❑ Distance to nearest: Well Foundation Property Line y0 SEEPAGE PITS ( I Depth Size Number (� SUMPS D Distance to nearest: Well Foundation . Property Line A DISPOSAL PONDS ❑ 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, 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 must call for al ctions. Complete drawing on reverse side.' Signed X Title: — Date: �2 FOR DEPARTMENT USE ONLY Application Accepted by Date L Area Pit or Grout Inspect y Data Final Inspection by f / Date 7 Iqq Additional Comments: L e. G al f/ r lo—Z7_ I t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385y� G ^V—S Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 AK CA 95201 f1 c5 bit) FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH13.24(Kv.fin5) 1z / l��7 07- EH 14-28