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APPLICATION FOR PERMIT It� SAN JOAQiJiN LOCAL HEALTH DISTRICT el ; �j 1601 E. HAZEL T ON AVE., STOCKTON, CA , Ij Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l a 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... r Job Address --ee— _ City Lot Size PM Owner's Name � � �"'�'� VAdss _. PhoneContractor's Name e No. Phone TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ ; PUMP•INSTALLATION ❑//" SYSTEM REPAIR I-] OTHER El 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑-Open-Bottom-G-Manteca----Dia:,of:Well-Excavation-=-- - .-...Dia.-of-Wel4-Casing El Domestic/Private t ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public rb "; ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irriga_tion ,�___4pprox. Depth 0 Eastern Surface Seal Installed by V� Repair Work Done ❑.;,Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material (top 501 ! pepth{ Filler Material (Below 501 TYPE OF SEPTIC WORK: 1NEWIINSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTION ❑ (No septic syatem permitted if public sewer is �,,� available within 200 feet.) r '` E- ` r ` Installation viwill serve: Tes'dente_ Comm�ial Other Number of living units:" , Number of bedrooms Character of soil td-a depth of 3-feet: Water table depth SEPTIC TANK ,T p/Mfg k Capacity No. Compartments �D PKG. TREATMENT PLT. ❑ Method of Disposal <, i Distance to nearest: Well Foundation Property Line r,N LEACHINGJL NE 16 No;& Length of lines"—, IWVTotal length/size FILTER BEP'y ❑ Distance to nearest: Well Foundation --Property Line SEEPAGE PITS t ❑ Depth Size 41,3 Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ` t DISPOSAL PONDS ❑ i. If 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 District. ^t _ Home owner or licensed agent's signature certifies the following:-1 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 certffy 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.' 'g The applica for tl requir spections. Complete rawing on r rse side. SignedX Fin ` Title: Date: • F L)l FOR DEPARTMENT USE ONLY ,i. Application Accepted by # Date Area a -f Pit or Grout Inspection by Date , Final Inspection by Date v� ,�Ad itional Comments: u r tXStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, St ., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH .i + EH 13-24{REV.14183) EH 1428 o -