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APPLICATION FOR PERMIT , t SAN JOAQUIN LOCAL HEALTH DISTRICT ,�� 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 Sah 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.- . r Job Address /� ye:E RIOX City 151W441_..Lot Size PM l Owner's Name &A�4A Address /147�_ Phone Contractor CS. ! Address License No. Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION, ❑ SYSTEM REPAIR ❑ •:>-" ,. - ...a: OTHER O: " "- DISTANC SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE n FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS =INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.-of vation Dia. of Well Casing ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other ❑ Delta Depth of Grout Seala of Grout I I Irrigation --Approx,"Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well DiameterTp Sealing Material(top 501 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I`1 REPAIR/ADDITION I i DESTRUCTIONV INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms k' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i Y, PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ."Wei[ 'Foundation Property Line l I Y SEEPAGE PITS [ I 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"wiil be done in accordance with San.Joaquin county ordinances, state laws_, and rules and regulations of-the San Joaquin-Local Health District. s- 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,l shall employ persons subject to workman's compensa- tion laws of California." The appliea t c I for all required inspections. Complete drawing on reverse side. �p Signed Title: ? Data: 6 -17 U 1 { FOR DEPfkRTMENT USE ONLY 4 �-� /� Application Accepted by t.0 Date J r Area I ' Pit or Grout Inspection by /Date Final Inspection by DateNY/ Additional Comments: ❑ Stk 466.6781 ❑ Lbdi 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 95201FEE . INFO AMOUNT DUE AMOUNT REMITTED O K H RECEIVED BY DATE PERMIT NO. +.EH 13-24 tFIEV.riKs1 EH 14-28