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100, �� APPLICATION FOR PERMIT mit 4— SAN JOAQUIN LOCAL HEALTH DISTRICT C'1J", 1601 E. HAZELTON AVE., STOCKTON, CAx Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /u-Iy YY 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 I Local Health District. (jrYll�S City it��ry Lot Size PM Job Address � Q { Address Phone O Owner's Name Co Contractor's Name ic u J ansa Na. — Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ THER ❑ DISTANCE TO NEAREST: SEPTIC TANK N A1SEWER LINES &04)57 DISPOSAL FLD.4O��PROP. LINE LLQ " FOUNDATION 0AJf_ AGRICULTURE WEUti+t�AI OTHER WELL A 476 PITS/SUMPS 915 INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS / Dia. of Well Casing _ ❑ Industrial ❑ Open Bottom E3 Manteca Dia. of Well Excavation a ' IN'Domestic/private 1�(Gravel Pack ❑ Tracy Type of Casing Specifications _ ' ❑ Public ❑ Other ❑ Delta Depth'of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth El Eastern Surface Seal Installed by W Repair Work Done ❑ .Type of Pump ., Ham= State-Work-Done, Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 13 (No septilable sy tem emitted if public sewer is 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 E SEPTIC TANK .. . ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size [` I FILTER BED ❑ Distance to nearest: Well Foundation Property Line pW SEEPAGE PITS ❑ Depth Size Number �1 y SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f hereby certify that I have prepared this application avid 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."Contractors 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 applican call for all required inspec'0 S. Complete awing.on reverse side.or ' Signed Title: ��I� ��' " Dater Al.— DEPARTMENT USE ONLY N ,Jlib ' Application Accepted by Date Area Z 4y Pit Pit or Grout Inspection by Date Final Inspection Date Additional Comments: ❑ Stk 466-Ml ❑ 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"NO. INFO + EM 13-24(REV.101831 EH 14-28