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J 0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., "STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for 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 P ,City of Size _ PM VIJ 8o Owner's Name _ Address Phone WZZO �. ' Contractor's Name+ &'InIVNO. �"'� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 'El PUMP INSTALLATION ❑ SYSTEM REPAIR,❑ / OTHER'Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL`D. PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k 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 ❑ Public -- ❑"Other 'w --- ❑ Delta—I!, Depth of Grout Seal Type of Grout r❑ Irrigation �Aprox. Depth"❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump +t_H'.P. State Work Done Well Destruction r ❑ Well"biometer ` Sealing Material itop 501 Depth f Filer Material (Below 50`1 TYPE OF-SEPTIC WORK:',.NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION"❑ (No septic system permitted if public sewer is .r � available within 200 feet.) Flnstallation will serve: Residence Commercial,— Other r Number of living units:'" Number of berooms . ' / iy Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT,PLT. F7Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE E$-INo. & Length of lines I "Y f1 ti Tot length/size FILTER BED ElDistance to nearest: WeiY-t��h> Foundation_ .. Property Line 0� k dl SEEPAGE PITS Depth Size , Number _� SUMPS E] Distance to nearest: Well160 Foundation - Property Line 4 100' a DISPOSAL PONDS ❑ 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 thework 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, I shall employ-persons subject to workman's compensa- tion laws of California." The applicant mvst call all required in tions. Completed wing on re side. i 11 -� Signed Title: }"^3 A Date:, FOR DEPARTMENT USE ONLY Application Accepted by D4. Date z Area - Pit or Grout Inspection by Date Final Inspection by Date T Additional Comments: � tk 488-6781 ❑ 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 96201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.101831 { EH W28 i