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i APPLICATION FOR PERMIT / 4} I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �J . Telephone (209) 466-6781 a _ 4 1908 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) ENVIyyRppOrr,AM'�ry'E-NTAL {HEFFA��LTH 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein hrfer-flih�d.�hrg�p�Itff Ari is j 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. s Job Address /7� /r��'��'y� City Lot Size PM Owner's Name T— �✓�t s-- Address /�t> /��'/'Ltd — Phone 9� Contractor ti Address �G License No Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION 1:1 PUMP INSTALLATION SYSTEM REPAIR 51� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. . — AGRICULTUREW.ELL,_ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Zi-Bomestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public n Other F1 Delta Depth of Grout Seal Type of Grout I I irrigation --Approx. Depth l I Eastern S rface Seal Installed by Repair Work Done ❑ Type of Pump �~4� H.P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material 1Balow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Instaliation will serve: Residence_ Commercial Other ` - II 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. ❑ k Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 4 I Total length/size FILTER BED ❑ Distance to nearest: Well F Foundation" Property Line E SEEPAGE PITS I ) Depth Size ° Number SUMPS Ll r. 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 rules and regulations of the San Joaquin Local Health Doltrict. 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." x t The applicant mu call for al eq ire nspections. Co ate drawing on reverse side. Signed Title: Z. Date: 1-00 DEPARTMENT USE ONLY ` Application Accepted by Date /�y2W Area 11 Pit or Grout Inspection by Date Final Inspection by Date «12' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } EEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. h INFO GASH �] /� a.EH 13-24 iHErf.7 A5)EH 14-28 3 r / �Y �. 7CJS I 1 t