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APPLICATION FOR PERMIT AI` SAN JOAQUIN LOCAL HEALTH DISTRICT fo 1601 E. HAZELTON 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 Districct.$� $� / M L Job Address / v �+ �� + City / R Lot Size �+' PM Owner's NameV(J'a'r 1 &2843 Address,321 7 6/ /�'Y3 ip—c& , Phone Contractor Address License No. 71e73 6 23 Phone 0 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEMREPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /ed. f SEWER LINES =d0 DISPOSAL FLD. DG PROP. LINE FOUNDATION - ! AGRICULTURE WELL' 7 _OTHER WEL 00 ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /1 ❑ Industrial ❑ Open Bottom A Manteca Dia- of Well Excavatio - Dia. of Well Casing I X Domestic/Private A Gravel Pack CI Tracy Type of Casing PVC . Specifications C1 RS S L fs9 FI Public1-1 thef F1 Delta Depth of Grout Seal _ __ Type of Groutne$_E� ifl�Y I 1 Irrigation p r x. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOIT-ION I I DESTRUCTION I i INo septic system permitted if public sewer is Q 1 available within 200 feet.i 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 r 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 SEEPAGE PITS i I Depth Size Number SUMPS Cl 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, anor 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-forr whecil'�2fs permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant VrVst caVor all requirjW ins ctions. Complete drawing on reverse ide. g �J Signed X� IC _ Title: r � ' Date: ^�"�^ I FOR DEPARTMENT USE ONLY -7gor Application Accepted by Date — Afee P Pit o Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 635-6385 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 RECEIVED BY DATE �PEERMIT-NO. r EH 13-24(REV.1/n 5) \, p �""� EH 14-28 �t6