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APPLICATION FOR PERMIT ' Ar 4 SAN JOAQUIN LOCAL HEALTH DISTRICT , `e 1601 E. HAZE. OWAVE. -,STOCKTON, CA a W -SIA f V r Telephone(209) 466-6781 PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED •• �-� �:.:: »::ul�rxi,^:`� " .��(Complete in Triplicate). � . .. . . V 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 + madein compliance with San Joaquin CountyOrdinanceNo.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. `---' " -, ` i Job Address < ' r„ / LK City j i Lot Size r PM Owner's Name ” Address "� - Phone Wit. Q/ Contrac ., �} (Addr & ^� � �C/ �( Jf�7� License N Phone TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPL CEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca pia. 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 --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.t: State,Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler`Material /Below 501 Ile TYPE OF,SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is,' I °available within 200 feet.) " Installation will serve: Residence_ Commercial— Other _—Number of living units:= Number of bedrooms Character of soil to a depth of" feet:-----^ 1 Water table depth SEPTIC TANK ❑ Type9Mfg Capacity--. No. Compartments PKG. TREATMENT PLT. �J 7 ✓ Method of Disposal Distance to nearest: Well F Foundation Property Line A. 4N LEACHING LINE" Q & Length of lines r°""' Total length/size FILTER BED __ ❑ Distance to nearest: Well Foundation" Property Line ; ' { r ,/' I SEEPAGE PITS, © Depth 7 Ysize -" "" f Number : ...} SUMPS :: ly LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS' ❑ 1"hereby certify that I have prepared this application and that-the work will be done in accordance with San Jcaquin`county-ordinances, state laws, and tules',and regulations of the San Joaquin Local Health District.. .1.., 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.' The applic I for all requ' inspection Complete drawing on reverse side. Signed L _- _ Title: Date: OR DEPARTMENT USE ONLY Application Accepted byLAA Date ��~� cJ� Area Pit or Grout Inspection by Date Final Inspection by Dat, i Additional Comments: , ❑ Stk 466-6781 �Q Lodi 369-3621 i ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i r INFO �fAMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE /�� PERMIT'NO. t+ EH 143-24-28 I REV:i i H 51 ... _ 43�r:v �lilII�O0�� ,�`/,q ! [