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w. APPLICATION,FOR PERMIT ; -'SAN JOAQUIN LOCAL HEALTH DISTRICT 7 1601 E. HAZE"TON AVE.,-STOCKTON, CA 4 Telephone .(209) 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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..549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. _S k Lot Size �.� l:� PM Job Address oC � !� as` m City Owner's NameAddress Phone fl f.. 4T Contractor s Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK WER LINES" DISPOSAL F D. PROP. LINE FOUNDATION AGR LTURE WELL OT ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUC SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype o asing Specifications ❑ Public ❑ Other ❑ Delt Depth of ut Seal Type of Grout ❑ Irrigation —Approx. Depth astern Surface Seal.I tailed by Repair Work Done ❑ Type of Pu H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is 6 available within 200 feet.l Installation will serve: Residence_ Commercial. Other Y Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: t " 4 SEPTIC TANK ❑ Type/Mfg Capacity No.-Compartments PKG. TREATMENT PLT. ❑, , i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines f - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' j f y SEEPAGE PITS 171, Depth Size' " Number i SUMPS" ,.❑ . Distance to nearest: Well foundation Property Line ! DISPOSAL PONDS ❑ I 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,I shall employ persons subject to workman's compensa- tion laws of California." ' nt must tali for all required inspections. Complete drawing on reverse side. Signed Title: 3 Date: FO =;� �` U` ON'-'-Date Y Application Accepted by �; C ��--� _ Date / Area Pit or Grout Inspection hV Date Final Inspection by. Date 0 Additional Comments: c '._ - .+� ~ ,_ t ❑ Stk 466-6781. . ❑ Lodi 369-3621 ❑ nteca 823-7104 ❑ Tracy 8355-6385 " Applicant- Return all copies to: Environmental Health Permit/Services"!601 E. Hazelton.Ave.,'P.O. Box 2009, Stk., CA SUM [ x FEE I INFO AMOUNT DUE-, AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. - + EH13-24(REV.r/n 51 T t_n�C3` - EH 14-28 —),3—LA