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APPLICATION FOR PERMIT "" .�y t• SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. LJobs /0O 6 �Or Coal/p�E yea City Lot Size PM ame/^1 1/ I�1/y Address /D010 SO C OC7L -F L 11Er Phone 1` Address License Ko. Phone WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTVRE WELL OTHER WELL I PITS/SUMPS I INTENDED USE TYPE OF WELL PROJ3LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Specifications 17 Public ❑ O ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation , App,... Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done._ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Fillet Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION 1.7 REPAIR/ADDITION I ) DESTRUCTIO I (No septic system permitted if public sewer is vailable within 200 feet.Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms f� Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Welt 'Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS 0 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 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 applican st call for It requ�a ins�ecti ns. Complete drawing on reverse side. Signed X /11 Title: ___6Date: `4 FOR DEPARTMENT USE ONLY //�� G� Application Accepted by Date �1 ""� ~-~ C�l C'A Area Pit or Grout Inspection by Date Final Inspection by 6- c _ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369421 ❑ Manta 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 FEECK INFO AMOUNT DUE AMOUNT REMITTED ;CASH RECEIVED BY DATE PERMITNO. EH14�2e-241REV.r/x5f 3s-a6 z EH 17 Z Yof? —A9-6t3 L I