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4PPLI .TION FOR PERMIT SAN JOAQUIWLOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Y 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 i Local Health District. ° PM CLot Size Job Address i �r r� - 3 Phone 3 Owner's Name. ` ddress P;250 �rv'"'�"""' License No �� Phone ' Contra�� ~- TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT ❑ w —DESTRUCTION ❑ PUMPINSTALLATION ❑ 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 C3 Manteca Dia. of Well Excavation Dia. f Well Casing E3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('I Public 17 Other ❑.Delta Depth of Grout Seal Type of Grout — I l Irrigation --Approx. Depth { I Eastern Surface Seal Installed by - Repair Work Done ❑ Type 4f Pump H.P. State Work Done_ y Well Destruction ❑ Well Diameter Sealing Material )top 501 r Depths Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION {.l DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet,) h/\ I Installation will serve: Rdsidetice_ Commercial'— OtherV��J�} Number of living units: L Number of bedrooms Water table depth Character of soil to a depth oti3 feet: SEPTIC TANK �� ❑ Type/Mfg Capacity � No. Compartments PKG. TREATMENT.PLT. C1- Y Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ _ No. & Length of lines Total length Isize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1.1 Depth Size 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:;"!ctirtify 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 us uire ctions. Complete drawing on s:e side Signed Title: �,tP�r �� Date: 2&1_1 � OR DEPAF�TMENT USE ONLY i Acce ted b v"� ' Date tU Area Application p Y Date t Final-Inspection by- lezZ Date 1 a Pit or Grout inspection by � r f Additional Comments: ` V J ❑ Stk 466-6781. ❑ Lodi 1 136-3621 ❑ 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 CK.0F FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. LINIOv EH13.241REV.t/rill ��' r ' EH 14-2a