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APPLICATION FOR PERMIT A i SAN JOAQUIN LOCAL HEALTH DISTRICT U 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 s PERMIT EXPIRES '1 YEAR FROM DATE ISSUED 1 IComplete 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 IS-3P - City Lot Size PM 9, 39411/4 Phone Owner's Name � //Vis'� Address _. �' � S-R � _ ,. s��f��a_ 19 O License No4:53 �— Fhone�� Contractor Addres TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION K 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 KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout i I I Irrigation .-Approx. Depth ( l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump�-ll�.�.+'!�^' H.P. P3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r 4F Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I A DESTRUCTION ( I (No septic system permitted if public sewer is C available within 200 feet.) JJ Installation will serve: Residence_ Commercial_ Other O Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth 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 f SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared-this application arid 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 Di3trict. 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must c li for all required inspections. Complete drawing on reverse side. G Signed X Title: _____ Date: fORD RTMENT USE ONLY 4 Application Accepted by Date Z Area I Pit or Grout Inspection by Date Final Inspection by a, Data r' E Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 GApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24{REV.1/851 EH 14-29 2NIS / 6 �•1