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I� APPLICATION-FOR PERMIT I. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i° Telephone (209) 466-6781 p ti•. F 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 r Local Wealth District. .�i' 14 _PeZ� t Job Address /��/ City Lot Size PM Owner's Name v �N/V&� G /`�°' +ddress — ��1f� Phone --> aContractor's Name Ys Phone License No. 7 TYPE OF WELL/FUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ID PUMP INSTALLATION © 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 PROBL-EM,AREA '�CONSTR.UCTION SPECIFICATIONS ❑ Industrial L1Open.Bottom D Manteca .Dia. of W611 Ocavati6h - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑'Tracy ' Type of Casing rWSpecifications El Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type"of Pump H.P. State Work Done i Well Destruction - ❑ Well Diameter Sealing Material (top 50') 1 Depth Filler Material (Below 501 d TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRUCTION❑ (No septic system permitted if public sewer is � ,l available within 200 feet.) i Installation will serve: Residence— Commercial_ Other 3 _ �.. i 1 Number of living units: N Number of bedrooms Character of soil to a depth of 3 feet: F Watel table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, D 1 Method of Disposal Distance to nearest: Well Foundation Property•L•irie LEACHING LINE No. & Length of lines ,� Total lenbth/size i FILTER BED ❑ Distance to nearest: Welles Foundation Property tine SEEPAGE PITS , /Depth __Size SUMPS ❑ Distance to nearest: Well Foundation ProFe'rty_Linte,, ) 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. --\ -'*,.�;% -'k t ' 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." Q� The applicant s call for al requi in pectin . Complete drawing on reverse side. . {, a. e I itle: _ •��&O%ezx Date: Signed '° i r II FO EP TMENT USE ONLY 3f Application Accepted by Date Area �r Date Final Inspection by K Date Pit or Grout Inspection by — k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835.6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI/TAO. INFO ��D� �.S3.S-Q k + EH 1&24(REV,101831 i EH 14-26 _ > _