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APPLICATION FOR PERMIT '4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA �i Telephone (209) 466-6781 PERMIT EXPIRES '('YEAR FROM DATE ISSUED . (CompletI3 in Triplicate) Application is thereby made to the San Joaquin Local Health District for alpermit 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. ob City Lot Sze PM :�i ' - Phone Owner's Nam A) Address Contractor sly► iC. Address_1E�� 11 .�x3 �1 License iVo Phone. TYPE OF WELT-/PUMP: NEW WELL C1WELUIREPLACEMENT El DESTRUCTION El i Ir PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TIIO NEAREST: SEPTIC TANK SEWER LINESh DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS ', a INTENDA USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial �I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '# ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications # ❑ Public 171 Other f.-1 Delta-"""_-Depth df Grout Se`aI-' Type of Grout I s I 1 Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump _ H.P . 11 State Work Done _ i } Well Destruction ❑ Well piamet`e`r Sealing Material (top 501 { ill Depth Filler Material (Below 50') . I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is I i ii available within 200 feet.} Installation will serve: Residence Commercial Othe?` �' I Number of living units: { Number of bedrooms 3 t # Character af-soil_to,a�deptf%of 3 feet: AIlDyS < Water table depth i l li .i i SEPTIC TANK ❑ Type/Mfg '� �M Capacity_ No. Compartments ; PKG. TREATMENT PLT. ❑ tM {r y 0.i j Y j` Method of Disposal Distance to� nearest:,, Well, s ,; .1 Foundation' Property Line d t' r LEACHING 11 NE No. & Length of lines, Total length/size FILTER BED ' ❑ Distancelto nearest: Well 1°� FT�tFnundation Property Line ` + !1 I SEEPAGE PITS Depth �f Size Number SUMPS L Distance�to nearest: Well Foundation Property Line ? DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wor /-will be,done in accordance with San Joaquin county ordinances, state laws, and ` rules and regulations of the San Joaquin Local Health District. =,, a Home ownerj�or licensed agent's signature certifies the followings`.',l cerir y that in the performance of the work for which this permit is issued,, shall not t 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 issueri, I shall employ persons subject to workman's compensa- tion laws of California." t The applicant must call for all re red.in ctions. plate drawing on reverse side. 1 �p r Signed `�I Title: II Date: iM r :I FOR DEPARTMENT USE ONLY Application Accepted by -_ I�. Date / L / ( Area ` tPit or Grout Inspection by Date r Final Inspection by Date i Cmments: Additional ❑ Silk 46614781 ❑ Lodi 369-3p621 ❑ Manteca 823-71041 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 MOUNT REMITTE" -J CK AMOUNT-DUE RECEIVED BY DATPERMIT'NO, INFO CASH T+'-fH•13-24(REV.5/n 51 I� Y f VZ IlRq-15_7 EH 14-2e � �. 1