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APPLICATION FOR PERMIT ��a SAN .fOAQUIN LOCAL HEALTH DISTRICT V� 1601 E. HAZELTON AVE., STOCKTON, CA O �$B Telephone (209) 466-6781 a>�1� PERMIT EXPIRES TYEAR FROM DATE ISSUED ��pME`��AR�j� (Complete in Triplicate) 104l RM��J5E Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workein 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 � �e��/�I ��'� /�-�'/ Ciry7/le f/!- at Size PM �"7 d2�1 Owner's Name a ��O Address G Phone Contractor s{�>Pi C2 Address v License No 2 Phone TYPE OF!WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 17SYSTEM REPAIR ;l( OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑—n `Tial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing ,ZDome'stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Publicn Other + F7 Delta Depth of Grout Seal Type of Grout i I Eastern Surface Seal Installed by 1.1 Irrigation --Approx. Dept I Repair Work Done E71 Type of Pumpu� H.P. State Work Done Well Destruction ❑ Well Diameter 6 Sealing Material Itop 501 I Depth Filler Material I6elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/.ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Residence Commercial Other Number of living units: Number of bedrooms Aaracter of soil to a derpth of 3 feet: Water table depth SEPTIC TANK EIType/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation ' Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER lBED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS C I Depth Size Number SUMPS Ll Distance to nearest: 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 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 • certifieslthe 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 law's of California." i The applicant m t I r all required i pections. Complete drawing on reverse side. 1�_� . Signe �X �`rl Title. .7�a/Gf///�i'•c/DSC rL- Date:FOR DEPAR�MENT USE ONLY Application Accepted by Date Are I Iate ff Pit or Grout Inspection by Date Final Inspection by 3- 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, Stk., CA 95201 i FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE f ERMIT�N0. INFO CASH +.EH 13-241REVI.I�K 51 ✓ S' jo } EH 1428