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APPLICATION FOR PERMIT—� SAN JOAQUIN•LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON 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. .. 1 .,.s tY • r � Q� i Job Address City Lot SizeSV vc-�+� xs PM Owner's Name ? 24�POVAdclress Phone — Contractor - - ddress � 4 5 . 143 3XP �s, U L'tense No. Phone � /�C T TYPE OF WELL/PUMP; NtW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR-0— -•-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 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private EI Gravel Pack ❑ Tracy Type of`Casing Specifications } ❑ Public a ❑ Other ❑ Delta Depth of Grout Seal Type of Grout + ❑ Irrigation I —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Hone ❑ Type of Pump H.P. State Work Dane Well Destruction } ❑ Well Diameter Sealing Material (top 509 "" ! t Depth E Filler Material (Below 509 r s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION/ INo septic system permitted if public sewer is available within 2 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 f Character of soil to a depth of 3 feet: I Water table depth I` SEPTIC.TANK # ❑ Type/Mfg } Capacity No. Compartments r w PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ' WelI Foundation L Property Line X s it LEACHING LINE ❑ No. & Length of lines ' Total length/size ` FILTER BED ❑ 'Distance to nearest:---Well, Foundation Property Line f` I � SEEPAGE PITS ❑ 'Depth Size Number r G� SUMPS ❑ TDistance ta.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. l Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the workforwhich this permit is issued, 1 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 Car rnia." The applican st call for all re fired inspections. Complete drawing on reverse side. ! i If 4 Signed Title: U- ys Date' i '"� FOR DEPARTMENT USE-ONLY Application Accepted by pate v (� Area '. Pit or Grout Inspection by -ate, .Final Inspection by XUA, ate _S7 Additional Comments: ❑ Stk 466-6761 t ❑ Lodi '369-3621 ❑ Manteca 7104 * •❑ Tracy MS-6385 M Applicant- Return alhc opies to:: Environmental Health Permit/Services 1601 E.;'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT SUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT•1V0. + EH 13.24 1REv. /a 57 EH 14-26