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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1,601 E. HAZELTON AVE., STOCKTON, CA �', r Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �rs (Complete in Triplicate) 2, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This RRI-��on is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an quin Local Health District. I3F1tYY�t K�4�+ �-y- FERMI-f/S tS Job Address (! �1 i �/�- City�f Lot Size PM Owner's Name Address Phone Contractor RMCA110)6 Address -2 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ t WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION VJe4 e ,,17SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE j--^FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE `'YYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial —0.Open?Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracyl Type ype of Casing Specifications F1 Public / f 1t OtRr ❑ Delta Depth of Grout Seal Type of Grout _ I I irrigation i ki `A�pprox. DepthI ioq Eastern Surface Seal Installed by p Repair Work DoneF}rpe of Pump �f/U H.P. G State Work Done Well Destruction .' iO"Well Diameter� ( Sealing Material (top 501 kj `F .I Depth t Filler Material (Below 50') V TYPE OF SEPTIC WORK: NEW INSTALLATION'(1 REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is ! 1� available within 200 feet-1 Installation will serve: Residence_ Commercial—I Other Number of living units: Number l bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Lengm of lines 1 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth ! Size Number SUMPS L7 Distance to nearest: Well Foundation 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 Dristrict. 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 applicanta squirepp_ 'ons. Complete drawing on rave a side. Signed X _ Title: Date: Z � FOR D RTMENT USE ONLY r Application Accepted by 4 A#A _ .Date �f �" Area -`-" Pit or Grout Inspection by Date Final Inspection by Date l 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, Stk., CA 95291 FEE INFO MOUNT DUE A{M�OUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. ♦..EH EH 1 �f 14-26 3-21(REV.rirs5l 7' rVA