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APPLICATION FOR PERMIT 0-f 5%0 SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL TION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .: : . (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 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 C" ��4.ot Size PM Owner's Nan+ Address S`_ f Phone 1 �, Address License N Contra j�1FE_L� (,r� �✓�/'��_ _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 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 ' ❑ Ind Tial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout a ❑ Irrigation —Approx. Det ❑ Eastern Surface Sea! Installed by , Repair Work Done ❑ Type of Pump XU'43 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r + Depth Filler Material {below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer.is (�(� available within 200 feet.) Ji Installation will serve: Residence— Commercial m____ Other Number of living units: Number of bedrooms Character of soil'towdepth-of'3-feet. Water-table-depth SEPTIC TANK ❑ Type/Mfg �% f Capacity - No. Compartments, 1 PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well' """'"- ',Property Lines"""'""` r 1 0 LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ is 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. f f i 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, I shall employ persons subject to workman's compensa- tion laws of lifornia." The applica t ust call for'al ;requiredomplate drawing on verse side. Signed j' Title: Date: P � �. O FOR DEPARTMENT USE ONLY I e— �� # Application Accepted by "' r Date ( Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE ii INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NO.x + EH1124 MV EH 14-28