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APPLICATION-FOR PERMIT [`— SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE, STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11 ;.ter. (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 SanJoaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 10 7�1 `7 � it ..4, C�1'l.{" '� r--.; ., 'a � . ; •,,�,f /I ��i i".F+,-. : :`i,''� Job Address CitS!C/ Y- Lot Size PM l Owner's Name c ' Address-- P [ �. I one gs Contractor 7A),r- Address J r 10cense No. Phone TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SKEPTIC TANK SEWER LINES T- DISPOSAL FLD. P FOUNDATION- AGRICULTURE WELL OTHER WE PITS/SUMPS _ INTENDED USE TYPE OF�WELL 0R0811EM AREA CONSTRUCTIO IFICATIONS ❑ Industrial ❑ Open Bottom '` [I Manteca Dia. e I Excavation i � �,.,,,c,k� I � � Dia. of Well Casing 1:1 Domestic/Private ❑;Gravel_Pa ---4 ❑ TracyType of Casing Specifications F ❑ Public n!Other ❑ D' Depth of Grout Seal Type of Grout V� ❑ Irrigation —Approx. De stern Surface Seal Installed by r Repair Work Done ❑ Type of P . "" - "H:P. �" _ w" - State Work Done �-- Well Destruction ❑ i e_ter f r Sealing Material it op 51 Depth j Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is -� available within 200 feet.) f; Installation will serve: Residence£ Commercial_ Other i Number of living units: �L Number of bedrooms j i Character of soil to,a depth of 3 feet: Water table depth I SEPTIC TANK e�$ ❑ Type/Mfg Capacity No.'Compartments : PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑' �INo. & Length of lines Total length/size! FILTER BED ❑ i�Distance to nearest- Well Foundation Property Line SEEPAGE PITS ❑ Depth; Size = - Number SUMPS ❑ IDistarice to nearest: Well Foundation- !Property Line ,I DISPOSAL PONDS ❑ M . 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 agents 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 mariner-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." The applicant st call for all:require inspections. Complete drawing on reverse side. Signed Title: Date: kj FOF?DEPA�fiTMENT i113E QNLYr>Y�f/fr/V`r >' ' L Application Accepted byDate Zf F Area Pit or Grout Inspection b h Date Final Inspection by 14 Date Additional Comments; t ❑ Stk 466-6781 ❑ Lodi 369-361 ❑ Manteca -7104 .. ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 3009, Stk., CA 95201 FEE AMO fNT DUE AMOUNT REMITTED- "CK RECEIVED BY INFO ry CASH DATE PERMIT N0. i -+ EH 13-241REV,1/x5) I-. 00 t � ' EH 1429 �'•�3 E I '