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APPLICATION.FOR PERMIT ' SAN JOAQUIN.LOCAL HEALTH DISTRICT 15-5 1601 E. HAZELTON AVE., STOCKTON, CA i 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 E made in compliance with San Joaquin County Ordinance No.54.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District-W ' .tj/C�sL C Job Address City ~ T ,e'r� Lot Size [ /�� PM Owner's ]Name � ;W//45 ct,ddress %Za �*4W14�E Phone �� " i Contractor nr_�Y —/O Address License No. -lr;?nPhone_f/ _ TYPE OF WELL/PUMP: NEW WELL ❑ SWELL REPLACEMENT'❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ I - SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE x FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBERWAR A-1 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca';4; Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑�TFacV- - Type of Casing Specifications ❑ Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout— C1 Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump.i - - -'H:PState Work Done Well Destruction ❑ Well DiameterSealing Material (fop 501 Depth 1 Filler Material (Below 501 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_ Commercial_ Other Number of living units Number of bedrooms i b Character of soil to a: epth of 3 feet: Water table depth - SEPTIC TANK Type/Mf Capacity No. Compartments PKG. TREATMENT PLTU.❑ F Method of Disposal: , 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tdtal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number ; SUMPS ❑ .Distance to nearest:- Well Foundation""''-s k' Property Line ' 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, l 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 ca or all Iuired ins actions. Complete drawing on reverse side. Signed X Title:. / Date: 7` FOR DEPARTMENT USE ONLY Q Application Accepted by Date V Area Pit or Grout Inspection by Date _� Final Inspection by t' Date 0 / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104" ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 y I FEECK 9. INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. + EH13-24(REV.1/9 5) EH 14.28 • Q�