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APPLICATION FOR PERMIT A SAN JOAQUIN LOCAL HEALTH DISTRICT ( V 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "t (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address`3) `i 1 � `�� City I.E Lot Size PM Owner's Name 6 r� `� �C -!/Ji AAddress 3' .32 - QL� hone C Contractor . Address SO.LL License No. Phone TYPE OF WELL/PUMP: NEW WELL 11 WELL RE CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ^f1`.J SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 L4Depth Filler Material (Below 50') .� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is y��`r��`��,. available within 200 feet.) Installation will serve: Residence_ Co martial_ Other Number of living units: I NumbereLbedro s Character of soil to a depth of 3 feet: Water table depth?%A & d,'0 SEPTIC TANK Type/Mfg L] acity Q apNo. Compartments tS/ PKG. TREATMENT PLT. ❑ Method of Disposal n Distance to nearest: Well -__MIA Foundation Property Line i LEACHING LINE No. & Length of lines �— �� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line SEEPAGE PITS Depth .1. Size 33�' Number Q N6 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1J " 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." The applicant mArl for all r uire in ctio Complete drawing on reverse side. Signed'X // — ��r� _ Title: Date: FOR DEPARTMENT USE ONLY y� ation Accepted by Date .3 U S Area it Grout Inspection by ate47:� Final Inspection byAL� Date it Comments: wry C ❑ Stk 466-6781 ❑ Lodi 36b-3621— ❑ Manteca 823-7104 ❑ Tracy 835-6388 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE IN AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. a EH 1124(REV.1/8 5) EH t�2s F I I Y3/ -V-s 3