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E f �S -7-�� APPLICATION FOR PERMIT Q �] k SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZETON AVE., STOCKTON, CA I Telephone 12091 466-6781 PERMIT EXPIRES tYEAR FROM DATE ISSUED y A (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.54.4 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. C7 Job Address 77 3fisQ1aA + LA City Lot Size�[i C_ PM { Owner's fVameC1`tUC-9 1rAddress R5 Phon Contractor��4� Addfess_ No. Phan TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications k f'1 Public ❑-Other ❑ Delta i Depth of Grout Seal Type of Grout I I I Irrigation r ..Approx. Depth l I Eastern Surface Seal Installed by- Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I Z REPAIR/ADDITIONDESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence>L Commercial_ Other Number of living units: _J__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 76 SEPTIC TANK ❑ Type/Mfg apacity No. Compartments PKG. TREATMENT PLT. ❑ . Method of Disposal Distance to nearest: Well Foundation Property Line Z� LEACHING EINE No. & Length of lines Total length/size 2 i FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS Depth Size 16 Number r SUMPS D Distance to nearest: Well r Foundation _ Property Line l 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 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 applicant must call for allll,requi ed ins ctions.Eompl drawing verse side. 1P L Signed Title: Date: FOR DEPART T USE ONLY Application Accepted by Date �� Area Pit or Grout Inspection Date Final Inspection by F- Date 0 Additional Comments: ��"�-3 �� f �""" f" "t D l ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 635-6385 vaH- -- `Tu e 4-Y'e-f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + I-fly4jeo Vet) FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. �r �L 1 INFO CASH a EH 13-24(REV,i/H 5) EH14-N - -