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7# APPLICATION FOR PERMIT - �Y fry SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �J0 W AQ- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �>LApplicationishereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is liance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin istrict. SL City Lot Size ] 1l PM - Address 7 L 2 Q S ` Phone 1 { _Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACXRER DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE Wkdr OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ De Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l astern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NE STALLATION I I REPAIR/ADDITION I I DESTRUCTI I i(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: sidence_ 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 Total length/size 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 Di§trict. 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." The applicant mut call for all required inspect Sons. Complete drawing on reverse side. Ct\- ��gned X 'M A01 I Title: 0.. — Date: i FOR EPpA ENT USE ONLY Application Accepted by /°S_?t�e� ` 1O�.nDate �sV �J Area I Pit or Grout Inspection by Date,,,,,,Final In pection by e Dat F yam° t Additional Comments: 0 V_S t/'s + �'✓ �— ❑ Stk 466-6781 ❑ Lodi 343621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant 35 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201FEE INFO MOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY �\�D�eA7TE fpPPEERMIIT'NNO. +.EH13-2t(flEV.iixs) EH 11-26 L:— ✓ ✓ 7617 <� •..J