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K APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE E ON AVE., STOCKTON, CA E - Telephone (209) 466-6781 `PERMIT EXPIRES TYEAR FROM DATE ISSUED ! {Complete in Triplicate) Application is heieby 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 �-7 m. Lot SizePM �/ P�, Owner's Nam M Address -- Phone it � Contractor d &UWre,, Z i se N Phone TYPE OF WEL IPU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION .I�. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ IndustrialLJOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domesticltrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation 1 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 (top 5 Depth Filler Material (Belo I TYPE OF SEPTIC WORK: NEW INSTALLATIp AIR/ADDITION 14 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation 'will serve: Restence Commercial_ ther ti Number of&iving units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments d PKG. TREATMENT PLT. ❑ / r Method of Jisppqa Distance to nearest: Well Foundation Property Line i . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED J .❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ,'1 1 Depth a Number ISU i� ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 ownerlor 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 fiiNowing: "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 must II for all re a inspections. Co plate drawing on reverse side: Signed X I�f PC, & - - - - 1Title: Date: 4 7-Z FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout II� spection by Date Final Inspection by Date r p r 0 067 Additional Comments: �y'^"i7 U E�we Pl Tk !"r 12 ❑ Silk 466-6781 Cl Lodi 369-9621 ❑ 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 !. FEE INFO AMOUN�TlDAUE AMOUNT REMITTED CASH RECEIVED BY DATE Gi PERMIT NO. + EH 13.24 IREV.i i w 5i R d 7 r -' f 7 EH t4-26 I iii