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Sl- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601'E. HAZELTON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) F 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. .a Job Address WAITCity Ae, I Lot Size PM Owner's Name rO Address (�3 7 1404'!K'�2fl.G1 Phone 3& 3 Contfactor I V (t� Address�l '/�. t�C�1� Aon. 64IT-License leo t��3 Phone �- ,TYPE OF WELL/PUMP: p NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONX� �_ Y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑— OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f' J ❑ Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private: ❑ Gravel Pack Ij Tracy Type of Casing Specifications f`! Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Doner Q/' WeIVDestruction �'+ Well Diameter/� -s `� Sealing Material [ � i?t e. 'J, Depth Filler Material (Belowe PeA e- TYPE,OF SEPTIC WORK: NEW INSTALJAIR/ADDITION I I DESTRUCTION I 1 tNo septic system permitted if public.sewer isim ��r o G e _ vailable=withitr200 r� Installation_will seives�Resideilc`e "Com rcra Other Nu`m`ber of living nits: Number of bedrooms Character of soil to a depth of 3 feet: r' Water table depth SEPTIC TANK 4 ❑ Type/MfgCapacity No. Compartments -.� F PKG. TREATMENT PLT. Ll Method of Disposal I 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 SEEPAGE PITS f I Depth Size r -,Number -SUMPS f 0 Distance to nearest: Well Foundation 9' Property Line DISPOSAL PONDS ❑ jhereby 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 forwhich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." �, Of The applicant must call for all required ins ctions'. Complete drawing on reverse Jeal— Signed , X Title: Date: { j FOR-DEPARTMENT-USE ONLY. Application Accepted by �CCrt� Date Q " T Area Pit or Grout Inspection by Date Final Inspection by Date 4�0 Additional Comments: Afl if ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835-Fi385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 i IEEE AMOUNT DUE AMOUNT REMITTED CASH'CK RECEIVED BY DATE PERMIT NO. 5 +.EH13-241REV.I/H5) / � `;, Ag,&_;P,5-y EH 14-26 f r� F lr