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APPLICATION FOR PERMIT ; - ." t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -�' Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED I (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 Lf� made in cornpliance with San'Uoaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District., 7"4/J � Job Address I' Z City t Size PM Owner's Name _ dFess /� Phone Contractor4�a - dress License No. �Phone_ t TYPE OF WELL/PUMP: NEW WELL ❑ VVELL REPLAPEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SY_ REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS {t ❑ In ria--I ❑.Open Bottom Ll Manteca Dia. of Well Excavatio Dia. of Well Casing 3 omestic/Ohvate ❑ Gravel Pack 0 Tracy Type of Casing Specifications; �r r ❑ Other F1 Delta Depth of Grout Seal Type of (aut, f`1 public ,. P I - ' t dation ��!._Approx. Depth i I Eastern Surface Seal Installed by - 1 Repair Work Done ❑ 4pe of Pump H.P. State Work Done ' 0. r Well Destruction` ❑ Well Diameter Sealing Material [top 501 Depth Filler Material IBalow 501 t — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted ifipublic sewer is ' available within 200 feet.) �- installation-wi[Lserve= Relr�;h+'dence—.�G rnmer-cial=-!Other 1 Number of living units: SIM Number of bedrooms ' 'Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK J © Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal i^ DistanoNto nearest: Well FoundatibO Property Line LEACHING LINE LI No. & Length of lines l Total length/size } FILTER BED Q Distanceito nearest: Well Foundation Property Line N SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C7. . I hereby certify that I have p!epared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 i 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 Ito workman's compensa- tion laws of Califo�cal " The applicant �Str i ired -nspections. Complete drawing on.' arse 'de. t Signed X JJ Title: date: FOR DEPARTMENT USE ONLY gi Application Accepted by E' Date < -Area J 2 pi' .c Pit or t rot Inspection by Date ._. Final Inspection by ._ Date/_ Additional Comments: II� ID Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies!6: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 952011 z r i ! FEE INFO AMDUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 'kn d +.EH13241REV.i/H51 I�✓f (�/IS �7 �. 1 EH 1426