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APPLICATION FOR PERMIT c = J SAN JOAnUIN LOCAL HEALTH DISTRICT 1601,E. HAZEI_TON AVE, STOCKTON, CA t� Telephone (209) 466-6781 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. t r Job Address City Lot Size S:cX PM Owner's Name Address `' , r Phone L,� ` 3 J op I... � Contractor Address I / /y �f Nt,O�., License No.7 S3 / Phone TYPE OF WELL/PUMP: NEW WELL LlWELL REPLACEMENT LJDESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f �t FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom-—.P-Manteca—Dia.-of Well-Excavation -- Dia. of Well Casing I {, E] Domestic/Private ❑ Gravel Pack LlTracy Type of.Casing I Specifications f E ❑ Public },fit❑_Other. ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation '_—Approx. Depth LI Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dont: Well Destruction ❑ Well Diameters Sealing Material (top 501 r ` Depth ! Filler Material (Below 501 JtJ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DES RUCTION ❑ (No septic system permitted if public sewer is # ilable ithin 200 feet.) Installation will serve:—Residence_F Commercial— Other ✓1/ C' Number of living units: w�Number of bedrooms Character of soil to a dtipth`of,3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg ) CapacityNo. Compartments PKG, TREATMENT PLT. ❑— '' t Method of Disposal CC 4C I Distance to,nearest: Wel!""F Foundation Property Line LEACHING LINE ❑ No. & Length of lines x Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line , P SEEPAGE PITS ❑ Depth Size = y Number I SUMPS ❑ Distance to nearest: Wel 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicanj must call all req " d inspections. Complete drawing on reverse side. liv'' Signed � Title: Date: r FOR DEPARTMENT USE ONLY/ --007Application Accepted by O 0.'V` Date � 3 Area Pit or Grout Inspection by Date ' Final Inspection by Additional Comments: 0 Stk 466-6781 i ❑ 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 FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO s j + EH13241REV.,/851 EH 14-26