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APPLICATION 'FOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZELTON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate). > ' 4 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 i 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 City , :Lot Size G4 PM Owner's Name Py� ( / 1 Address Z / / Z . ,F C'��i4� Phone � Contractor ddresIs T= icense No. �Phone W TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑fti, ,4 DESTRUCTION ❑ PUMP_INSTALLATION-❑ •_--:- . .RSYSTEM 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 El Gravel Pack a:.,❑.Tracys Type of Casing Specifications l ❑ Public ❑ OthI er ❑ Delta Depth of Grout Seal Type ype of Grout t ❑ Irrigation J4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 1 H.P:. State Work Done Well Destruction ❑ Well-Diameter Sialiilg' aterial (top 501 Depth =i- r7r k Filler Material (Below 501 -- - TYPE OF SEPTIC WORK: NEVILINSTALLATIONO REPAIR/ADDITiO DESTRUCTION.El (No septic system permitted if public sewer is available-"within 200 feet.) 1 Installation will serve: Residence Commercial F Other Number of living units:� Number of bedrooms Character of soil to a depth(of 3 feet: = � �/� ;� -� _--- Water-tabie`deptht ( SEPTIC TANK I ❑' Type/_M.fg _1 - .`^ _" � Capacity ryr No. Compartments PKG. TREATMENT PLT. ❑, r—-_.t Method of Disposal i i. Distance to nearest: Well� / � Foundation'— 7/property Line LEACHING LINE 1---No. & Length of linesTotal length/size O FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ =. Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ x i 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 compensatioA laivsof CaliforAia."Contractors 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 must call for al!iXyquir?d inspections. Complete drawing on reverse side. j _r : r s r Signed X ��'�` _ Title: f Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by Date Final Inspection b Date-4t Additional Comments: E r ; ❑ 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 FEECK 11 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. + EH1}Z4(rMEV.I/R 5) x .. EH 14-28_ »= �. ��. t' 7' I I� k.-3 �s l i