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4 - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 1" 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. Job Address City Lot Size � `y 3 Zr11PM Owner's Nam Address /OAF `��" , Phone Ay Contractor Address License No, Phone TYPE OF_WELL/PUMP:, - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing A i -❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications f l Public 0 Other Delta Depth of Grout Seal ° Type of Grout I Irrigation _.-Approx. D .l 1 Eastern Surface Seal Installed by I r.• Repair Work Done ❑ Type of Pump; ``' H.P. State Work Done_ Well Destruction ❑ Well Diameter ► Sealing Material (top 501 Y Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.I Installation will`serve: Residence_ Commefcial_ Other Number of living units: _Number of bedrooms .; I Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK ❑ Type/Mfg �- Capacity �" No. Compartments PKG, TREATMENT PLT. O """ IVlethod of Disposal Distance to nearest: Well Foundation ~" Property'Line t , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D 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 hrules 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 applicant must call for al requ e i spections. Complete drawing on reverse side. Signed .rTitle: Date: FOR DEPARTMENT USE ONLY �` �`� Application Accepted by01 Date`•, /- , Area C)_3 Pit or Grout Inspection by De 'f FinallyIInnspection In f r -Date 3 Additional Comments: ` 'etf!'�'uS O'4 � #�p C ( "`t�7z- 111 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO h J�fg / + EH 13-244 t i H 51 3, (�"G! /j�.r �L+ 6-154,7 y £H 14-26 �1 n�lJ' /ffjj�� 1 .,