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�0 APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. F Job Address City Lot Size PM • • P Owner's Name Address Phone r 52 Contractor Address , 1/60 ,/pox License No. _Mkt Phone {-✓� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION )A&JyW#_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 omestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Specifications t" Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern q Surface Seal Installed by Repair Work Done ❑ Type of Pumpt►jc� H.P. 1 RQY J�aAIIZb k5 State Work Dpne, ` Well Destruction 1-1WellDiameter Sealing Material (top 50'1 AMA #A a Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted it public sewer is lc� _ available within 200 feet.) S? Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 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 r - SEEPAGE PITS I I Depth Sixe Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line _�. .� ._.■,DISPOSAL--PONDS_ _ 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. 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 of sub-contracting signature certifies the following: "I certify that in the performance of the work for this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t - The plic must call for all re ed inspections Complete f J Signed X Date: ` �9 ' Cf - DEPART ENT USE NLY ,� 'y rw � Application Accepted Date _ Area Pit or Grout Inspection by D to Final Inspection by Date Additional Comments: Q Stk 466-6781 ❑ 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 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO" INFO CASH +.EH13-241REV.rixsf J EH 11-2a 1