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i APPLICATION FOR PERMIT `=, SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) ; i 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 of Size PM !J Owner's Name IB17ekt Pit Address —Of �_ .Sa- S,u ef at, Phone ZYVI Contractor S Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El • PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER-171— DISTANCE TO NEAREST: SEPTIC TANK ER LINES DISPOSAL FLD. PROP. LINE- FOUNDATION AGRI Ut-Tt7R OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL LEM AREA CONSTRUCTION SPECIFICA ❑ Industrial ❑ Open Bo ❑ Manteca Ilia. of Well Excavation Dia. 11 Casing ❑ Domestic/Private ❑ el Pack ❑ Tracy Type of Casing Specifications Cl Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout -- i I Irrigation _ Approx-�Depth I 1 Eastern Surface Seal Installed by Repair Done-- ❑ Type of Pump H.P. State Work Done_ W estruction ❑ Weil Diameter Sealing Material (top 501 ' Depth Filter Material (Below 50') 4. TYPE OF SEPTIC WORK: NEW INSTALLATION I1 -REPAIR/ADDITION Ir] DESTRUCTIONkVI (No septic system permitted it public sewer is N available within 200 feet.) Installation will serve: Residence_ Commercial— Other ;. Number of living units: - Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg "rtY Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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. I 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 app ca must call for all requirapkinspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ` Date ��7 7Area LJ✓„ _ �(` Pit or Grout Inspection b y Date Final Inspection by Date ? -3 U -7 Additional Comments: li4C ` LlStk 466-6781 ❑ Lodi 369-3621 ElManteca -71 ❑ Tracy 835- 5 � Applicant - Return all copies to: Environmental Health Par vices 1601 E. Hazelton Ave., P.O. BA 2009, S ., CA 9520T FEE INFO AMOUNT DU A�M7-`O�UNT REMITTED r ASH .�R/E'yCrELIVED BY DATE PERMIT NO. EH 3-211REV.1i45Y 0 1D � EH429 U 0 061L