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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL'HEALTH DISTRICT , 1,L 1601 E. HAZEL T ON AVE., STOCKTON, CA - Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the4R41es and Regulations of the San Joaquin Local Health District. `' City LotSizePM Jab Address 7 / gyp ' Phone Owner's Name _M�.fg� ��* Address' ,, �y Contractor, _ Address G LI ns,a No. Phone?` TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-� DISPOSAL FLD. PROP. LINE v FOUNDATION AGRICULTURE WELL OTHER WELL-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation it Dia. of Well Casing 7Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �f Type of Grout I Installed b urface Sea Y ❑ Irrigation �Approx. Depth ❑ Eastern � ; , H.P. -'S State Work Don t Repair Work Done j Type of Pump L s Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0 a(No ailseptic em permitted if public sewer is 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 N4;.,Compartments PKG. TREATMENT PLT. ❑ }� r Method of Disposal Distance to nearest: Well Foundation Property Line r e LEACHING LINE ❑ No. & length of lines Total length/siz , .� FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size, Number SUMPS Ll Distance to nearest:-_ ell Wfoundation r `_ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will Ibe done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health 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."Contractors 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." The applicant mt call r all r equired inspections. Complete drawing on ere side. 47 Signed T Title: x� r�cr' �L r 7 ' - - �'� _tri FOR DEPARTMENT USE ONLY Lr Date / m(4 �rea c� / Application Accepted by �q I� Date Final Inspection by Pit or Grout Inspection by ? rev Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f 0 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., Gi -i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE RMIT N0. 1NF0 LL + EH 13-241REV.1/e 5) ,s� 0v ,�-�CO EH 1428