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APPLICATION FOR PERMIT �3 I �+. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 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. j 41-JAand"i JabAddress 7 City, i., PM Owner's Nam ContractorAddress 1 +<O73. License No./6 Phone Vim 41 TYPE OF WELL/PUMP: ii NEW WELL 9--' WELL REPLACEMENT 4+; DESTRUCTION PUMP INSTALLATION I�e SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ Oo INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,Aomestic/Private 11?travel Pack ❑ Tracy Type of Casing } Specifications M Public n Other n Delta Depth of Grout Seal Type f Grout V I I Irrigation AW Approx. Depth i I Eastern Surface S al Installed by _ Repair Work Done 17 Type of Pump 2Z 1 H,P. I State Work Done Well Destruction bgo"Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 fil r'AIR/ADDiTION I I DESTRUCTION I I 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ll Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to neatest: Welt Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coulnty ordinances, state laws, and rules and regulations of the San Joaquin Local Health D1'ltrict. , Home owner or nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any arson in such m nner as to b come ct to workman's compen tion laws of California."Contractor's hiring or sub-contracting signature certifies t following: "I certi hat in an of the wor is is armit is issued I shall employ persons subject to workman's compensa- tion law of Califor ia." The ap licant al requi do omelet drawing n a i a. Signed Title )ate: FOR DEPARTMENT USE ONLY rr QQ Application Accepted by "" Date �~L c:;;U Area O 3 Pit or Grout Inspection y D nu Final Inspection by Date l -1 `�rw Additional Comments: ' L 1,] LI.Sf lt' 1+17 tT* 1JC1r.} ❑ 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 INFO AMOUNT DUE AAMOUNT REMITTED C K 9 RECEIVED BY /y7 DATE ry' PERMIT'NO. + EH134IpEV.F i H ti) " ,..J�v`-� 4J � r ! // 00 EH I