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jGf APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA `n rare .It LOCA Telephone (209) 466-6781 mi DIST RI v 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 Coun 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 O !.i! City t Size PM Owner's Na • �"'N'r Address ` 3—�,% LPhone Contractor's Name l .r License No. CSf to/A 1_3 73 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Rio"" 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 ❑ In�strial r El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation /AApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done EV Type of Pump s_W. H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Orr, t Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is a available within 200 feet.l Installation will serve: Residence_ Commercial_ Other CR 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ - _- — __ ..r,-...� 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 Joaquin Local Health District, Home owner or lic ed agent's 'gnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe in such manna as to become subject to wo man's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo wing:"I certify t tin the perfor ce ofZra rk for 1c this permit is issued, I shall employ persons subject to workman's compensa- tion laws of aliforni .' The applic nt m al require ng on reverse Signed itle: Date: FOR DEPARTMENT USE ONLY / }� Application Accepted by Date p�/ Area 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 AMOUNT DUE AMOUNT REMITTED CK* INFO CASH RECEIVED BY DATE PERMIT NO. { + EH 1324 IRM 101831 �1.�7 —�._" q ^1 EH 14-28