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! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT P 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - -r •'_ (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 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. % 7� 42-0 '' k Job Address rf / �' — �n City � fH of Size PM Owner's Name IFI-t'Y� +St4l^vr i'1._— Address , Phone I Contractor 7�Pr Addres License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑f SYSTEM REPAIR ❑ OTHER D - y"DISTANCE-TO-NEARESY:=SEPTIC-TANK _SEWER LINES: DISPOSAL FLp�. r "PITS/SUMPS - FOUNDATION AGRICULTURE WELL OTHER WELL�(L_ r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TI S LIIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing Domestic/Private 'CGravel Pack ❑ Tracy Type of Casing If Specifications FI Public Cl Other f� Delta Depth of Grout Seal Type of Grout40se I - rV I I Irrigation —.-Approx. Depth kastern Surface Seal Installed by I.t,�l1l�. � 0/r Repair Work Done ❑ Type of Pump H.P. State Work Done_ b Well Destruction Weil Diameter , { Sealing Material (top 501 nm or p e Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is (iI available within 200 feet.) i r 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11' Depth Size — Number S!)INPS' __�L"1 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 rules and regulations of the San Joaquin Local Health Di§trict. 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 `t 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." r The applicant 5t all for II req re inspections. Complete drawing on r�seside.. [,� r� Signed X Title: Date: { ��'"` r® FORjDEPARTMENT USE ONLY Application Accepted by Dat A i rArea g P� Pit or Grout Inspection by Date Final Inspection by ✓`v Date V Additional Comments: In - ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 37104 ❑ Tracy 635- OAI.4. Qhs 018 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201�'eLl E `J d lGwu�g4t'd2/\ -FE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. J INFO CASH k +.EH 13-24(REV.1/H 5) /3p Q Q f EH 14-26