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11� APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL-'HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA j± •Telephone (209) 466-6781 r i PERMIT EXPIRES 1'YEAR'FROMDATE ISSUED' I11 ,'.1^, (Wriplete in Triplicate) .I _ "• 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 Ryles and Regulations of the San Joaquin Local Health District. _'k I� !! 3 ,� City �_ Lot Size f PM Job Address / �. . � -(�m Phone '~ - me. ddress117k.3 '� Owner's�Na f� 1 Contractor ress License NoI� Phone TYPE OF WELL/PUMP: NEW WELL F7 WELL REPLACEMENT ❑ DESTRUCTION LJ I- PUMP INSTALLATION ❑ SYSTEM REPAIR.( OTHER ❑ I: �' DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBL_ E AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open,Bottom�';t ❑ Manteca Dia. of Well Excavation Dia. i f Well Casing € Type of CasingSpecifications p'Domestic/Private ❑ Gravel'Pack ` ❑ Tracy ❑ Public ❑ Other a Delta,l Depth of Grout Seal Type of Grout ❑ Irrig4tion ---Approx. Dep'h) ❑ Easterh Surf ce Seal Installed by Repair Work Done LX Type of Pump,, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f II Depth -^ ^` ..` Filler Material iBelow 501 TYPE fOF SEPTIC WORK: NEW INSTALLATIOFN ❑ AIR/ADDITION ❑ DESTRUCTION ❑ INo availablelc system w within 200 feet.) if public sewer is 4 Instillation will serve: Residence— Corri�ercial� Other Number I of living units:T Number f bedrooms ` r Water table depth I' f soil to a de th'of 3;,`feet,- ,-- ------_ Character o p _ ,.. - -.._ _,�-._ _.--...,.. . Capacity r-_._ ._--,—.-:----.•..� SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 Tl length/size El otae LEACHING LINE No. & Length of linesf FILTER BED ❑ Distance'to nearest: Well _ Foundation Property Line .�...�..y __. a..- v Y SEEPlAGE PITS ❑ Depth Size * - Number SUMPS ❑ 'Distance to nearest: Well Foundation ProQerty Line 1 DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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 mariner as to became subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following:"l certify that in the performance of tWwork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California. The applicant call or all required inspections. Completedrawing on reverse side. I 1111 + bate: i . le: . �^. Signed )C ,•, Fi R DEPARTMENT USE ONLY 3 s Date Area Application Accepted by ILd Pit or Grout Inspection by Dated Final'Inspection by Date -Additional Comments: ❑ 5tk 466-6781 ❑ Lodi 3693621 ❑ 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 CK* RECEIVED BY DATE PERMIT"N0. INFO97 AMOUNT DUE AMOUNT,REMITTED CASH EH 13-24 f. tv.5/a 51 ' EH 1426: w - I