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le APPLICATION FOR PERMIT �to � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address.06-6 � _.�'�i City r Lot Size PM r Phone �^ 3 3 7171 Owner's Nam r Address Contractor `✓ Address e444, License N1l/LX _3 Phonw- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other F 1 Delta Depth of Grout Seal Type of Grout I Irrigation _Approx. Dept I i Eastern Surface Seal Installed by. Repair Work Done LST Type of Pump H.P. _ State Work Done Well Destruction D Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') _ V TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION i I (No septic system permitted if public sewer is 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 Capacity No. Compartments PKG. TREATMENT-PLT. ff] Method of Disposal Distance to nearest:' Well - Foundation — f Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line A. SEEPAGE PITS I 1 Depth Size Number SUMPS `[_� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I hatre 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 Diktrict. c 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-inzuch manner as to become subject to.workman's_compansatior4Jaws-0f_California_�;.Contr_actor'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 rrAsi call for all required inspections. Complete drawing on rave se side. Signed X ills: "�l/t� Date: FOR DEPARTMENT USE ONLY Application Accepted by ' r\ T Date r r f'^� 0 Area Z r Pit or Grout Inspection by Date Final Inspection by �' , Date Additional Comments: ❑ 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., CA 95201 FEE INFO AMOUNT DUE - AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +.EH13-241REV.t/951 r VVV EH 1428 OQ,3