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• APPLICATION FOR PERMIT a SAN JOAO.UIN`LOCA• 4� LTHYISTRICT 1601 E. HAiE"�TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' ri (Complete in Triplicate) ,3 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 to iI7�„ a., w• y E1d v: ', -�� „ Local Health District, � � n � " '� Job Address `"` ^O City Lot Size_�6tl x Q V 7PM /.;1 or':f is ` - _ •ie Owner's Name � " Address ( " 4' Phone OF Jag ContractorS r��lt�Al!5 Address'�a5 /AIZoKoAJr License No., y/-sy-) Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑'� It DESTRUCTION El` PUMP INSTALLATION.Ll SYSTEM REPAIR#❑ �— „r r OTHER El .n 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 ❑ MantecaDia, of Well Excavation Ria. of Well Casing ❑ Domestic/Private ❑ Gravel Pack # ( ❑ Tracy-' 00 Type of Casing Specifications ❑ Public ❑ Other v{`4 3 al ❑ Delta' Depth of Grout Seal Type of Grout ❑ Irrigation ___--Approx:,Dep h ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. I State Work Done ► Well Destruction ❑ Well Diameter, "l — - Sealing Material it p 501 Depth + Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i t available within 200 feet.) Installation will serve: Residence Commercial Other I' Number of living units: -0— Number of bedrooms \1 I Character of sail to a depth of 3 feet: Cl.�.1 ? Water table depth SEPTIC TANK 9 --Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ze ' Foundation l0 Property Line LEACHING LINE lid/"No. & Length of lines Total length/size "n FILTER BED ❑ Distance to nearest: Well ZSO- f Foundation,A— Property Line SEEPAGE PITS ❑ Depth Size %,V `'S Number SUMPS ❑ Distance to nearest: Well Foundatson `- r fN Property Line i DISPOSAL PONDS [-J 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. s 1 t 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 t employ any person in such mariner 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 compense- tion laws of California." The applica alVfor ! requ re inspections. Complete drawing on reverse side i - + 1IK-' •� Signed Title: Date: t OR DEPARTMENT SE ONLY $ Y ApplicatioWAccepted by Date Area Pit or Grout Inspection byDate F al Inspection by} Date r� + Additional Comments: 3 3 ❑ Stk 466-6781 ❑ Lodi 369-3621111 ❑ Manteca 823-7104 ❑ Tracy 835-6385' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMk1TED CASH RECEIVED BYDATE PERMIT`NO.' + EH.1324{REV.1/B 5) .,. ,,y�,y ...�-.-'�,+..:ter n ,.iwr..'..rA..;.+�.. .., EH 14-28 U I