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APPLICATION FOR PERMIT SAN.JOAQUIN LOCAL HEALTH DISTRICT 4, 1601 E. HAZELTON AVE., STOCKTON, CA �5 Telephone (209) 466-6781 J U L I PERMIT EXPIRES 1 YEAR FROM -DATE 'ISSUED ' ENVIROMENTAL HEALTH. v = F ;(Complete in Trjpllcate) PERMIT/SERVICES c 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 Ryles and Regulations of the San Joaquin Local Health District. ,. • Job Address City)_01Lot Size c,. :'; PM. Owner's Name Zt4, Address 'L Phone [l Contractor/ Address License No. 26 Phone*Z dam' I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ :.oa PUMP,INSTALLATION.-❑ SYSTEM REPAIR ❑ OTHER X_ �= 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_SPECIFICATI_ONS . .. ❑ Industrial ❑ Open Bottom '❑ Manteca Dia. of Well Excavation Dia. ell Casing ) pomestic/Private ❑ Gravel Pack ❑ Tracy Type Of Cesing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal,Installed by y Repair Work Done Type of Pump H.p. {' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'} Depth Filler Material-!Below 56') ., TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is a .,. 1 :: -; available within 200 feet.) Installation will serve: Residence Commercial, Other 1 ' Number of living units: Number of bedrooms �. > Character of soil to a depth of 3 feet: ' 4 Water table depth SEPTIC TANK ❑ Type/ Capacity No. Compartments I PKG. TREATMENT PLT. ❑ ^�-«- ,., .,__ L IMethod of Disposal ! Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line a SEEPAGE PITS ❑ Depth #" Size Number SUMPS ❑ ~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 Bounty 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 applicantust call f all required inspections. Complete drawing on everse ide. Signed Title: Date: F FOR PARTMENT USE ONLY Application Accepted by Date C ",� Area Pit or Grout Inspection by Date Final Inspection by pate Additional Comments: DS"tk 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 CK 0 FEE INFO AMOUNT DUE I. AM/O`UN/T(REMITTED CASH /RECEIVED BY t^� DATE ,PyE^]RMIT'NO. + EH 13-241REV.t/651 EH 1426 U a �L+ ' vO 69 /7� G-11