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APPLICATION FOR PERMIT 1� r SAN JOAQUI.N LOCAL HEALTH DISTRICT �l 1601 E. HAZE T ON AVE., STOCKTOIV, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED > d (Complete in Triplicate) Application is heieby 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 Cit Job Address Y Lot Size l Address PhonOwner's Name J I 72?d Contractor Address cense Noz 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: of Well Casing ❑ Domestic/Private ❑ Gravel Pack d Tracy -Type of Casing Specifications 1`1 Public n Other Ll Delta Depth of Grout Seat Type of Grout _ I I Irrigation _.-Approx. Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Belo i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 DESTRUCTION I 1 1No septic system permitted if public_ sewer is available within 200 feet) Installation will serve: Residence Commercial= Other Number of living units: Number of bedr oms . (Q'f i4 Character of soil to a depth of 3 feet: ;Water table depth yi SEPTIC TANK ❑ .Type/Mfg 7✓ f' Capacity t No. Compartments r PKG. TREATMENT PLT. ❑ atr '�, Method of JDsposal Distance to nearest: Well/0-0-4 Foundation Property Line LEACHING LINE ❑ No- & Length of tines Total length/size ,.. FILTER BED ❑ Distance to nearest: Wekl Foundation 4-Property Line i r SEEPAGE PITS r I I Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will bedone 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 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 alk r it i ctions. Comp ete cawing on v se side. Signed X Title: � Date: FOR DEPARTMENT USE ONLYApplication Accepted by i J 4 Date Area Pit or Grout Inspection by Dgte Final inspection by D�attj Old L— Additional Comments: Q C/ C,cG1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. �] +.EH 13-24 IR v/M51 d j ATEH 14-28 19 . 6