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A43-33 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON 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. Job Address CitS4y11 .L i7e PM Owner's Namedress 3 �f( " Phone Contractor ddress L�10�3?aphone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE 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 { 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation /_.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done Lel Type of Pump ` �P H.P, //` State Work Done Well Destruction ❑ Well Diameter Sealing Material;(top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 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 F 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 Distance to nearest: Well Foundation Property Line DISPOSAL P S El I hereby rtify that I have prepare this application and that the work wi be done in accordance with San Joaquin county ordinances, state laws, and rules a regulations of the San Joa uin Local Health District. Home wrier or licensed agent's sig ture certifies the f Ilowing: "I ertify that in the performance of the work for which this permit is issued, 1 shall not empl any person in such manner 0 to ecome ubje t w rk n's c pensation la s of California."Contractor's hiring or sub-contracting signature certifi s the following: "1 ce 'fy th in a perfo enc f h w for ich t ' rmi s ssued,I sh e y persons subject to workman's compensa- tion I s of California." The ap licant must call re it ins pe ions to ring on r arse s' e.� Signed X le �1 J�' n �J V 0 OR D RTMENT USE ONLY /f Application Accepted by Date JF— Qs Area Pit or Grout Inspection by Date Final Inspection by Date lac Additional Comments: ❑ 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 INFO RECEIVED BY CASH DATE PERMIT NO. +.EH 13-24(REV.t/H5) �J /�� EH 14-28 c/ !7