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APPLICATION FOR PERMIT I RMIZ40 CTSAN JOAQUIN LOCAL HEALTH DISTRI 1601 E. HAZEL T ON AVE., STOCKTON, CA F P 4{ Telephone (209) 466-6781 �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUMVIROMENTAL HEALTH (Complete in Triplicate) FERMITAERVICES 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 i.C(� �C.9 _ .,. City Lot Size PM Owner's Name ca c� ,j� �� 0 �� e� AddressR �--- ' one ContractorJC Address 0 Licens'e No. r Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ] i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing '�omestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation - Approx. Depth l I Eastern 5uriace Seal Installed by Repair Work Done 9— Type of Pump. (r; H.P. LI—Q— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I ) lNo 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 ❑ r Type/`Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ` F ' Foundation Property Line 3 LEACHING LINE ❑ No. & Length`of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11. Depth Size tv Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line 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 i rules and regulations of the San Joaquin Local Health District. ' 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."Contractors 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 parsons subject to workman's compensa- tion laws of California." I The applicant must ca for all re ui ctions. Complete drawing on reverse side. i Signed X � " Title: Date: n- T -FOR DEPARTMENT USE ONLY h' Application Accepted by Date /� Area Pit or Grout Inspection by Date Fina! Inspection by &0 Date ALL�-ELY Additions! Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 C1 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEE] CK RECEIVED BY QjPERMITJ'NO. INFO CASH ATE Ett a.EN 14]8 14-21(REV.riK51