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4 T APPLICATION FOR PERMIT 4, ES SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 the Rules and Regulations of the San Joaquin Local Health District. Job Address climr Cit n Size PM I j Owner's Name MvAddress _f�tf '!_ `Ll � _ Phone tit 12 -7AqjZ6 1 1 ' Contracl&V& � e r*_Addressff�� bLicense No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL £i1-WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A EA CO CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications F1 l Public fl Other Delta th of Grout Seal Type of Grout i I Irrigation _Approx. De h l I Eastern Su a Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 '. REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other 1 Number of living units: Number of bedrooms _ y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity i No. Compartments PKG. TREATMENT PLT. ❑ y„ r Method of Disposal Distance to nearest: Well Foundation 1 Property Line ' LEACHING LINE ❑ No. & Length of lines T 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 ❑ t I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 shalt 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 applic nt m st call for I r quirad inspections. Complete drawing on reverse side. �" } (� Signed IJ� Title: Date: FpR DEPARTMENT USE ONLY J Application Accepted by f Date .3 Area l } Pit or Grout Inspection by � ate FiPaI Inspection by Data Additional Comments: -errn'' () ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 7 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO 'AMOUNT DUE AMOUNT REMITTED GSH RECEIVED BY HATE PERMI7'NO. rEH1 -24iREV.t/n51 EH 144-28 �/r1�r� 7—!�D7