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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .� 1601 E..HAZELTON AVE., STOCKTON, CA3j Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , (Complete in Triplicate) �) �,�R� p HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worlEt"R � ttib� � cation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an�t.g �3idr4 -San Joaquin Local Health District. �� Job Address moi--/—�S..�I J� City Size PM Owner's Name�k ;,4Q MUk'A - Address SO(,/�,1�—ACAOI 4 �� Phone �� Contract Address r` © 1�iJ,k ! �Z.� License No. 6 373 Phone 66_ b TYPE OF WELL/PUMP: N W WELT_ ❑ WELL REPLACEMENT El / DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUC7.RE WELL _ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation,, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Depthc I_I Eastern Surf ce Seal Installed by Repair Work Done f�Type of Pump H.P. . State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _'Property Line LEACHING LINE ❑ No. & Length of lines TatalJength/si FILTER BED ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS I 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 - is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any son in such ma er as to become subject orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th ollowing: "1 certify at in the pert a fit ork for whicAr .it is issued,I shall employ persons subject to workman's compensa- tion laws f California." 44 The appli ant mu c 1 ff equired a awing on r Signed X v Title: Date: /f OR DEPARTMENT USE ONLY Application Accepted by -� Date ��`/�- "�iT Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: t ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ♦.t3H 3.24(REV.i i x s)1 EH 14-26 9/1- '$Z3