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APPLICATION FOR PERMIT o 3 L4-9 { + 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 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 PM Owner's Name _Z, 6Wy zy Address �l/ �d �4, „ � �"� Qa Phone ` Contractor e Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP INSTALLATION-O' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE OUNDATION AGRtCULTIjRE WELL OTHER WELL PITS/SUMPS INTENDED USE TY WELL PROBLEM AREA ---F+--lnclustrial t ❑ Open Bolt anteca -- -Dia. of Well-Excavation -- - .�.�_. -Dia. of Well Casing ❑ Domestic/Private ❑ Gr ck Tracy Type of Casing Specifications ('1 Public Other fl De Depth of Grout Seal Type of Grout _ i 111 I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by _ ( - Repair Work Done ❑ Type of Pump I H.P. State3Work Done _ Well Destruction ❑ Well Diameter `Sealing Material{top 50'1 Depth I Filler Material (Below 50') ; I TYPE OF SEPTIC WORK: NEW INSTALLKTION I 1 REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is Y vailable within 200 feet.) Installation will serve: Residence_ commercial_ Other F Number of living units: Number f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTGC TANK -❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �• Method of Disposal Distance toBarest: Well Foundation Property Line I LEACHING LINE ❑ No. & Lengt of tines - 1 Total length/size 1 — FILTER BED ❑ Distance to nearest: `�� WQII Foundation Property Line r SEEPAGE PITS l I Depth i Si a "" _ Number SUMPS D Distance to r3Earest: Well -" 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 ofthe San Joaquin L' cal Health Di§trict. Home owner or licensgd agent's signature rtifies the following: "1 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 b ome subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the perfotmance 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 all required inspections. Complete drawing on reverse side. Signed X ; Title: er.JQ,�t -�(k,Jy Date: 1�3 FOR DEPARTMENT USE ONLY J�-t Application Accepted by Date r LArea /_3 Pit or Grout InspectioDate Final Inspection by / �� d.�i Date Additional Comments: ❑ Stk 466-6781 ❑ 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, Silk., CA 95201 IEEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE _PEERS/MIT'NO. +.EH 13-21(REV.t t n 5) if-Y� EH 11-26