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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT r 1601 E. HAZELTON 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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatio}ys of di San Joaquin Local Health District. -/� j /� ��La"]rr Job Address �7 6. �`'�� =l `S Cm, p� 1 Lot Size A w PM Owner's Name F S r w �IAddress�� 22 Q J 6' 7 3 y ^ �- Phone Contractor �u r r �` WELL Address —2aZ(j [i. OW � License No."%9—U Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATIOf - SYSTEM REAP ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK L � SEWER LINES -hI DISPOSAL FLD. PROP. LINE T �� FOUNDATION" AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC I K ❑ Invial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j B;,mestic/Private mel Pack ❑ Tracy Type of Casin V 9 Specifications ❑'Public ❑ Other ❑ Delta Depth of.Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern urface Seal Installed by Repair Work Done ❑ T of Pump S_C1Z H.P._, to rk Done Well Destruction ;--CII Diameter �_ Sealing Material flop 501 C� " Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) 'V 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. ❑ Method of Disposal l Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line K SEEPAGE PITS ❑ Depth Size Number �`r SUMPS ❑ Distance to nearest: Well Foundation Pro party 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."Contractor's hiring or sub-contracting signature certifies the following:""I certify t in the performance of the work for which this permit is issued,I shall employ tion laws of California. persons subject to workman's rise- The applicant call f I d i s Complete drawing on xeivirse side.IV/ t E Signed 7,418:_ _ _ Date: FOR D ARTMENT USE ONLY j Application Accepted by v - Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk. 466-6781 ❑ Lodi 359-3521 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Servfoes 1601 E. Hazelton Ave., P.O_ Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH EN EM 1r-a14-211f 5-00 . 1&24(REV.I/as)