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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 City-441 Lot Size��.--,_—T_ PM Owner's Name Address Pho � Contract AddressLicense / Phor � r�� TYPE OF WELL/PUMP: y .,,. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE SOF WELL PRdt3LEM AREA-"-'CONSTRUCTION-SPECtFICATIONS'"r ❑ Industrial ❑ Open Bottom 1 ❑ Manteca Dia. of Well Excav Dia. of Well Casing ❑ Domestic/Private - •❑ Gravel Pack ❑ Tracy - T "sing Specifications f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth astern Surface Sea! Installed by Repair Work Done ❑ Type of P _ H.P. State Work Done Well Destruction Diameter Sealing Material {top 501 Depth Filler Material (Below 501 �e TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ADDITION l I DESTRUCTIO Na septic system permitted if public sewer is �,• F ^�-- ^— ----available within 200 feet.] Installation will serve: Residence— Commercial ' Othe-r' * y Number of living units: Number of bedrooms : Character of sail to a depth of 3'feet: r Water table depth SEPTIC TANK ❑ Type/Mfg _ T Capacity! No. Compartments PKG, TREATMENT PLT. ❑ _ "� r Method of.Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .. SEEPAGE PITS I I Depth Size Number SUMPS L-i 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 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 C 'fornia." The applican ust call for all required ins t' s. omplete drawing o�n r rse sideSigned X " Title _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspectio y D� Final Inspection by Additional Comments:' ��V�� t��`�� ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑Lodi 369-3621 Manteca 823-7104 Tracy 5-6385-6385 Applicant- Return all copies to: Ehvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO, + EH 13.24 1REV.I/x 51 - . EH 14-2e