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*-� APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA V Telephone (209) 466,6781 . '. :PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) :A Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinYdescribed.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__' Lot Sizer PM J� # Owner's Name Vy B� i6+ ��'` Address l�� 6 ,_ Phone ' S t Contractor s Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ElPublic LJOther ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, H.P. State Work Done Well Destruction ❑ j Well Diameter¢ Sealing Material Itop 501 Depth Filler Material (Below 50')- I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION VI-(No septic system permitted if public sewer is v1 t available within 200 feet. 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 SEPTIC TANK Type/Mfg.l. Capacity No. Compartments PKG. TREATMENT PLT.'❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line` 1 c: LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance to.nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this applicatiori 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 shad 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 theperformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." f The appiica must call for all req d ins ions. Comp drawing on reverse side. kSigned -__ Title: /�/ f rr�7 f 1" Date: �'�le t– 7 A FOR DEPARTMENT USE ONLY i Application Accepted by Date Area (� _ Pit or Grout Inspection {f nnDate n ! Final Inspection by, Dater Additional Comments: S�f�Yf ) �?Lt>Xf �.cPX�r Cour ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ hdanteca 104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 •' INFO FEE AMOUNT DUE CK AMOUNT REMITTED CASH RECEIVED BY DATE PERMT'NO. + EH1324(REV.t/e5) [ �� 1 ' EH 1,28 �f\ � I