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7:. 4F APPLICATION FOR PERMIT X` SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1609 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 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. Se �� 1 Y l Job Address , / City Lot Size PM Owner's Name !0 CORn Address PC. RnXit t, ! Phone Contractor ` ( ress License No.�_Phone i TYPE OF WELL/PUMP: NEW WtLL Pt— WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP lNS7ALLATION� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK _ SEWER LINES _�11L�`�,_,`�_`_,pISP05AL FLD.��,,, "�� `�PROP. LINE FOUNDATION � AGRICULTURE WELLOTHER WELD-PITS/SUMPS 1(1� [ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � II ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatfion--JE Dia. of Well Casing d Domestic/Private Gravel Pack ❑ Tracy Type of Casing_c�F� Specifications S 0 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout A3 / Irrigation ---Approx. Depth ❑ Eastern Suce Seal Installed by Repair Work Done Ot Type of Pump H.P. Surf State Work Dons Well Destruction ❑ Well Diameter Sealing Material (top 501 I l Depth f i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo 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 I r SEPTIC TANK Q Type/Mfg Capacity No. Compartments ' P,KG. TREATMENT PLT. ❑ Method of Disposal I §' Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation t Property Line '' SEEPAGE PITS ❑ Depth i Size ' t' Number SUMPS ❑ Distance to nearest: Well- -" Foundation Property Line DISPOSAL PONDS ❑ t~ t I hereby certify that I have prepared this application'and that the work will bebone in accordance with San Joaquin county ordinances, state laws, and F rules and regulations of the San Joaquin Local Health District. '. ; - - 11 Home owner or licensed agent's signature certifies the following: "I ceiW 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." li The applicant call for all required inspections. Complete awing on/5reverse side. Signed f Title:L Date: FOR DEPARTMENT USE ONLY s r� 7 ver Application Accepted by Date Ar i✓ Pit or Grout Inspection by Date ' X�Final Inspection b Date ii Additional Comments: f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-631 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO gMOUNT DUE — AMOUNT REMITTED 'CK RECEIVEDBY DATE PERMIT''N0. 4 " / + EH 13-24(REV.1195) �Q'`�� //`'} 2 7 I „ EH 14-26 Uri i Ii.