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r $ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 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 the Rules and Regulations of the San Joaquin p Local Health District. IceT.90 c<,,, diT lz—, 0� �ka N� W A City __W to �Lot Size r�� F isS PM Job Address ! Owner's Name Address t Ovt-1 + Phone r Woommo Contractor� Address l% License W 56f � Phone 916 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER P< SOIL.VA" IFS DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE Nf 8 W, FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F Public Other Delta Depth of Grout Seal Type of Grout ^� I i Irrigation _�fff.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter a� Q Depth Filler Material Gl TYPE OF SEPTIC WORK: NEW INSTALLATION ! 1 RCPAIRIADDITION i I DESTRUCTION l 1 (No septic system permitted if public sewer is 4�� available within 200 feet.) 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED O f JIA 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ` I I Depth Size Number ' SUMPS 14rN Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 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 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 applica mut ca l o 11 required inspections. Complete drawing on reverse side. Signed X Title: 51!1 Date: tali g FOR DEPARTMENT USE ONLY Application Accepted by Date /9-7-6-7 Area S Pit or Grout Inspection by Date Final Inspection by orf ` Date a �� 7 e-- Additional Comments: , v7e- ❑ Stk 466-6781 ❑ Lodi 369-3621 TI Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies tEnvironmental Health Permit/Services 1601 E. Hazelton Avg_, P.O. Box 2009,,9520 j •� w •��-�c,,� �, •(tee ffn! AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. I + EH 13-241REV.t/A5) 4 EH 14-26