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! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Ih PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x {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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. IM it Job Address X77 ic 00 C/pace "' City S/D T�tot Size PMP Owner's Name 22 6-6!9; / Address 37/7GD /dcztr Phone Contractor Address License•No. Phone TYPE'OFWELL-/PUMP:-._v, ,e,,— NEW WELL--0 -„,�,,WELL REPLACEMENT.CI,._ --,.DESTRUCTION ❑ � L_ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER �] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �PROFOUNDATION AGRICULTURE WELL OTHER SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CON STR PECIFICATIONS �! ❑ industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia.of Well Casing IM ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications j ` f'l Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout _ 1 1 Irfigation rox. Depth l I Eastern Surface Seal Installed by _ 3' Repair Work Done ype of Pump H.P. s` ' State Work Done I' Well pestru ❑ Well Diameter Sealing Material (top 50'1 A. k Depth Filler Material (Below 50'1 y i� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1_1 ^DESTRUCTION (No septic system permitted if public sewer is t available within 200 feet) Installation will serve: Residence Commercial_ Other' : !� Number of living units: Number of bedrooms . i Character of soil to a depth of 3 feet: x + Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments M PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation---, _ _ Property Line S I LEACHING LINE ❑ No. & Length of lines s Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 issue, I shall not ! employ any person in such manner as to become subject to workman's compensation taws of California.” Contractor's hiring or sub-contracting signature j 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." - k1 The applicant must call for all required inspections. Complete drawing on reverse side. 4� t Signed Title: Date: _ Z ",/ I�Application Accepted by FOR DEPARTMENT USE ONLYDataArea 0 ,i. Pit or Grout Inspection Date Final Inspection by �. � Date 'I 3 i Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 (1 k INFO FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERM17'ND. ♦ EH 13-24 4REV.I/K5) IWO /7 e 1 1