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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 9 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES (YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hateby made to the San Jbaquin 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 �� City i Lot Size < �C PM Owner's Name V • r Address G ✓�0:�r �/r ' 1-61"617K— Phone 3& 4 Conttactor� � Address License No. Phone TYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __T DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t�J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Botiom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications JJ M Public Cl Other 1 ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation T Approxi. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ % Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diamet;r Sealing Material (top 501 Depth = 4 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION I)QNo septic system'permitted if public sewer is liable within 200 feet`.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bed ooms Character of soil to'a depth_ of 3 feet;s. ,y� Water table depth SEPTIC TANK El Type IMfg 7 Capacity / No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal GkU4sl Distance'to nearest: Well 50 'Foundation 00 Property.Line i LEACHING LINE ❑ No. & Length of lines Total length/size ..FILTER BED ❑ Distance;to nearest: Well (LFoundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ® ❑ k 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, an rules and regulations of the San Joaquin Local Health Di1trict. '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 taws 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." f The applicant st II for al wired in ction Complete drawing on reverse side. / �7 d Signed X Title: _.., .,,,.------ Date: /" / b f" FOR.DEPARTMENT USE ONLY LY Application Accepted by .` Date 3 Area a� Pit or Grout Inspection by Date Final Inspection by �r Date l �� Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104L ❑ Tracy '835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IREV,t i x s] ( r'�5 � — U S-7 EH 14-2a v