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APPLICATION FOR PERMIT J ;x SAN JOAQUIN.LOCAL HEALTH DISTRICT 47- 1601 E. HAZELTON AVE., STOCKTON, CA ZA r Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in'Tripliicate) 1 Yrs'" t 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 �. �,.3?� ' City''r Lot; •Size PM Owner's Name Address `� � Phone �7 Contractor � L - Address�36 �L i` ® License5/1 Phone "� J TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFWELL�"PROBI ''R NSTRUCTION-SPECIFICATIONS'- I ❑ Industrial ❑ Open Bottomeca,Dia. of Well Excavation Dia. of Well Casing LlDomestic/Private LJGravel Pa ❑ Tracy` ; Type of Casing I Specifications ., ❑ Public ❑ r t ❑ Delta,' Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair one ❑ Type of Pump H.P,. State Work Done Well Destruction ❑ Well Diameter "Sealing Material (top 50') LDepth l Filler Material SBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑' REPAIRMDDITION'❑� -DESTRUCTION Nd septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other t s Number of living units: Number of bedrooms i s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl r , . j Method.of Disposal Distance to nearest: Well Foundation F I Property Line ` �ti y LEACHING LINE ❑ No. & Length of lines ` Total length/size t FILTER BED ❑ Distance to nearest: Well FoundationProperty Line 3 SEEPAGE PITS ❑ Depth Size- """"'Number SUMPS- ❑ Distance to nearest: Well Foundation Property Line .� DISPOSAL PONDS ❑ i 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 i i 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 mu call for all required inspections. Complete drawing on reverse side. # 1 � , Signed Title: ' Date: -,$ FOR DEPARTMENT USE ONLY Application"Accepted by - — -- - — pate- ''r Area l ' Pit or Grout Inspection b Date ' 'Final Inspection by Date i f Additional Comments: �` G li ❑ Stk 4W6781 If 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 gy,AMOUNT DUE AMOUNT REMIT-TED CAH RECEIVED BY DATE r-� PERMITN'0. + EH' 3-241REV.1/H51 \305' VK_ EH 142a