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I I r: APPLICATION FOR PERMIT ` s t SAN JOAQU'IN LOCAL HEALTH DISTRICT I V _ '.f 1601 E.4HAZELT ON'AVE.,:_STOGKTON, CA \Jll Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is-hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heremSdescribed his application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulato in's`tithe San Joaquin Local Health District. ,, i Job Address City PM � Owner's Name t "Address hone Contractor ddress 0.��6 License No. �� phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] 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 I CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 17 Other Ll Delta _Depth of-Grout Seal Type of Grout 1 1 Irrigation Approx. Depth l I E tern r Sup Seal Installed by Repair Work Done Type of Pump H.P. State Work Do Well Destruction ❑ Well Diameter Sealing Material (top 50') -------------- Depth Filler Material lBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I J INo septic system permitted if public sewer is ,f , available within 200 feet./ Installation will serve: Residence_ Commercial_ C!ther x Number of living units: Number of bedrooms F �ti Character of soil to a depth of 3 feet: l ------Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ �' -• - ' r ?.� 4 Method.of Disposal Distance to nearest: Well FoundationProperty Line r i LEACHING LINE ,❑ No. & Length of lines . ✓ Total length/sizeM r FILTER BED ❑ Distance to nearest: Well r' r Foundation Property Line fr- { F SEEPAGE PITS i1 Depth Size r Number ° SUMPS Cl Distance to nearest: Well I FoundationProperty 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 regulati n Joaquin Local Health District. j Home owner icensed agent' ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ an erson in such mann r as to become subject to work m ompensation laws of California."Contractor's hiring or sub-contracting signature certifies a following- "I certify a " the performa e If it e w for ich this permit is issued, I shall employ persons subject to workman's compensa- tion la of California " The a licant 11 c u e ired i t 4 awing n revs e. Signed tD Date: S F RIDEPARTMENT USE ONLY Application Aceepted.by f Date ! Area `I Pit or Grout Inspection by bate_ Final Inspection by Date<� i Additional Comments: CJ Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 41 RECEIVED BY DATE PERMIT NO. INFO CA + EH13-24 SREV,7 i e 51 l/ - EH 14-2a