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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 District. Jab Address✓ o �/� % ity d Lot Size PM Owner's Name le4l dl—re—C11— Address �z Phone O Contractor a Kfi Address ZV, d9,Q License No. Phone -3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ I - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO._ PROP. LINE_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LIOpen Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing d ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout--_ ngation _Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P._f 0 State Work Done _ + Well Destruction ❑ Well Diameter Sealing Material (top 50') �1//!.!-„!J✓J/�`!� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION Ll DESTRUCTION I 1 (No septic system permitted it public sewer is r'f available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms A' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line length/size lental LEACHING UNE L1 No. 8, Length of lines Total 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number _ SUMPS_ Cl --Distance to nearest: - Weil Foundation Property Line f 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 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 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 mus atl fA�ailre t inspections. Co Iota drawing on reverse side. S' nod Title Date: FOR DEPARTMENT USE ONLY/ Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: _ m mm ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., FEB 2 1 ^ ;1 � - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT • � HEX F INFO CASH Hl lXXI I f r'+ r ,ill�rti +.EH13-2EV.lik51 Z- EH t4-286