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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 F i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED H (Complete in Triplicate) Application is heieby 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 at-p c�t City " eea Lot Size PM C Address �/ Phone ��` Owner's Name erlQ7r-per x Address ``t�r License No. :?,P-r) ,2 Phone Contractor TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © P DISTANCE TO NEAREST_: SEPTIC TANK. SEWER LINES 13ISPOSAL FLD. _ PROP. LINE Y FOUNDATION AGRICULTURE WELL OTHER WELL �TA PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.,Approx. Depth i I Eastern -Surface Seal Installed by Repair Work Done ❑ Type of Pump — H.P. - State Work Don Well Destruction ❑ Wel]rDiameter Sealing Mateiial (top 50'1 h P Depth Filler Material (Below 501 �� 19 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) k Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: e SEPTIC TANK ❑ Type/Mfg Capacity o. ompa C PKG. TREATMENT PLT. ❑ nn Method of Disposal Distance to nearest: Well Foundation Proa&TLi& 6- 8 LEACHING LINE ❑ No. & Length of linesTotal SME lIT�( ERVICES k FILTER BED EI Distance to nearest: Well Foundation Property n � SEEPAGE PITS I I Depth Size Number - —SUMPS=-'r' ` L] Distancerto nearest:' '-' Well -�--^'Foundation- � -Property Line DISPOSAL PONDS ❑ `11 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 taws of California." Contractor's hiring or suer-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 applicantmu I for all recipirejrinspections. Complete drawing on r erg. r l Signed X Title. Date: A� FOR DEPARTMENT USE ONLY X i I{i kApplication Accepted by Date Area 7! Pit or Grout Inspection by D to Final inspection by Date/� Additional Comments: / `l ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 r /® j 0 l Applicant - Return all copies to: Environmental HealtFi Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i, INFO A`M�OUpUE AMOUNT REMITTED GASH RECEIVED BY DATlE� PjERMIIT'NO. j r.EH 13-24(REV.tn5) J+7 cNT`00 EH t4-26 q h