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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT t' 1601 E., HAZEL I ON AVE., STOCKTON,'CA Telephone (209) 466-6781 L i 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 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 Local Health District. a Job Address _I a Z . O� C r' City T 1V :Lot'Size PM �r u _l, /� /� a Owner's Name �1 ICICA 'h H LY-fAdd. -.!q1� "y . N �[l V - 9 Phone j..', Contractor + Address "" icerise No. Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT VDESTRUCTION Cir x PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC p r� ❑ Industrial 13 Open Bottom El Manteca Dia. of Well Excavation PVT Dia. of Well Casing �/ I dmestic/Private ravel Pack ❑� Tracy Type of Casing Specifications ❑ Public 17Other ii+ <Ita Depth of Grout Seal T of. ut /U / ❑ Irrigation �Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type,of Pump H.P, ti State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501)` Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 171 Distance tMethod of Disposal o nearest: Well Foundation Property Line LEACHING LINE ❑ _'No.4 Length of lines 9 Total length/size { FILTER BED ❑ Distance to nearest:• WeII Foundation Property Line r, SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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." 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 applica st r eq ' d inspections omplete drawing on reverse side. r--A ,�J ��p Signed Title: Date) /U OR DEPARTMENT USE ONLY + Application Accepted y Date �/��6 Area Q Pit or Grout Inspection by Data %� -M Final Inspection b wY Date y Additional Comments: ElStk 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 95201 i• FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Cry + EH W24 IREV.I/B 5) �, �� ._4 1 /b { 1 I, EH 1428 [ / C�_l"!