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.1 �iiv.ad APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �r`Q�xk. (�.��• (Complete in T.riplicate), 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 City L57"S-A �W Lot Size_�d 4) PM_ --� r Tpl f X Owner's Mame �d !f, / >�Address / 45?/ Phone `_S �.3 Contractor Address License No_ Phone TYPE OF WELL/PUMP: �P NEW WELL Eli WELL REPLACEMENT ❑ DESTRUCTION ❑ PUM ,+INSTALLATION III — SYSTEM REPAIR ❑ _ OTHER I-] 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL+FLD. !;PROP. I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI iCATIONS p ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing ❑ Domestic/Private 12Gr 9M el Pack ❑ T Type of Casing Specifications ' El Public ❑ OthIr ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �E rox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump F H.P. State Work Done Well De ton El Well Diameter Sealing Material (top 50') " Depoh Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW�IINSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is II vaiiable 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 )<Typ'.e/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f`I A#I Method of Disposal Distance to nearest: Well Foundation Property Line � F LEACHING LINE ❑ No �& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: o Well Foundation Property Line DISPOSAL PONDS ❑ 4 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 of the San Joaquin Local Health District. d 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 manne�as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature f 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." I _ z The a plicant must caEl for all required in ctions. Complete drawing on reverse side.".., dM, igned itle: � � Date: } i R DEPARTMENT USE ONLY Application Accepted by y .-,$, f Date Area Pit or Grout Inspection !'P Date12 Final Inspection by Date Jr7! Additional Comments: a ❑ Stk _466-6781 ❑ Lodi 369.3621 ❑ Manteca 7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. CASH + EH 13-24( REV.tiR5) �0 4- S EH 14-28 J� nl