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w APPLICATION FOR PERMIT '- `. SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I 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 welVpump and the Rules and Regulations of the San Joaquin Local Health District. i {I Job Address ,,�LleCity �� /e� ' Lot Size �+�� PM Owner's Name Lit/ � Address �?� �� Phone Contractor- Address r T License No. Phone_ $ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES- RUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ !i 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 r,., Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' 0 r ❑ Public Ll Other 1.7 Delta Depth of Grout Seal Type of Grout — I I Irrigation Approx, Depth I 1 Eastern Surface Seal installed by i Repair Work Done E Type of Pump I H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth j Filler Material (Below 501 y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION't I DESTRUCTIO ) (No septic system permitted it public sewer is I . available within 200 feet.) Installation will serve: Residence— Commercial_ Other k Number of living units: Number of bedrooms IF Character of soil'to a'dep1h'of'3 feet: `� Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ ! Method of Disposal n Distance to !nearest: Well Foundation Property Line t LEACHING LINE CI No. & Length of lines Total length/size r , FILTER BED ❑ Distance to nearest: Well "+ 4 Foundation Property Line '4 I SEEPAGE PITS I I Depth Size Number SUMPS L� Distance to nearest: Well -Foundation Property Line DISPOSAL PONDS 0 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 Di§trict. 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 taws 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," {d The applicant must call for it re ired in ctions. omplete drawing on reverse side. sa Signed X Title: D�c/i1I� _ Date: 8J� FOR DEPARTMENT USE ONLY Application Accepted by r ID e / QkI Area I3 1,P q. L s�Mfrd f Pit or Grout Inspection by Date Final Inspec ion by r Date Additional Comments: *. lit n Qa't<r0 6 cc c tf OVle, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 CK$11I fiECEIVED BY DATE �7PERMIT'NO. . EH 13-24[REV.t i k sl 2 I a 3 Q, - EFi 14-2t1 �J Lw�` !U