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i' APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CAS + j Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) II 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 ' 4d X1 j� "city � Lot size PM Owner's Name [ Address / .acs Phone Contract , Address V V' 11 1 Ove q{p] 102 1 43 License No. Phone TYPE OF`WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ s 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 j DIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } +❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications T, PublicL] Other n Delta Depth of Grout Seal Type of Grout iIrrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done .❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 11 Depth Filler Material (Below 501 w TYPE OF SEPTIC WORK: 'NEW INSTALLATION I') REPAIR/ADDITION 1 1 DESTRUCTION {No septic system permitted if public sewer is . available within 200 feet.) it Installation will serve: Residence_ Commercial— 'Other Number of living units: _. Number of bedrooms f f Character of soil to a depth of 3 feet: Water table depth rLJj1J SEPTIC TANK ❑' Type/Mfg Capacity No:Compartments P,KG. TREATMENT PLT. ❑ Method of Disposal li Distance.to nearest: Well Foundation Property Line y r LEACHING LINE ❑ No.,&'Length of lines11 Total length/size FILTER BED ❑' Distance to rnearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS ❑ Distance to nearest: Weil Foundation Property Line i 61SPOSAL 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 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 I mploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cbrtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- tion laws of California." �r The applicant st call for all required inspections. Complete drawing on reverse side. Date: Signed X Title: � _ Cy 4 jl 1 / FOR DEPARTMENT USE ONLY _ } Application Accepted by f _Date Area—v 7 '7 Pit or Grout Inspection b '''Date Final Inspection by ^-- Date 7— {y-7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,"CA 95201 II FEE II INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1 -24fREV.1/951 EH 11-29