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APPLICATION FOR PERMIT 7 SAN JOAQUIN LOCAL HEALTH DISTRICT �� I 1601 E. HAZELTWAVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �D • k (Complete in Triplicate) 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �7 1 .yam+ 1 _ 17 z,K t ri -L— Job Job Address 7 / 1/V . 1 l!1^Y)eIr City Lou Lot Size PM Owner's Name v Address �� r •�v — y ;,R— Phone Contractor's Nameicense No. J q �/ Phone 14 13 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN7;< DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ��O,.,THER ID � s DISTANCE TO !NEAREST: SEPTIC TANK 420 SEWER LINES DISPOSAL FLD.•1/Q PROP. LINE FOUNDATION AGRICULTURE WELL 2 "I OTHER WELL PITS/SUMPS INTENDED USE � fY E 01 WELL`"` 'PROS CEMAREA CWNSTRUCTION-SPECIFICATION ❑ Industrial /Mpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Dom ❑ estic/Private � Gravel Pack ❑ Tracy Type of Casing S'��,�„�� Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �(,�— Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work-Dor�e Well Destruction ❑ Well Diameter Sealing Material (top 501 — ;0_F►A_1e11 �" V Depth E Filler Material (Below 501 _ J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms �- Character of soil to a'depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v.. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE # ❑ No. & Length of lines '.Total length/side FILTER BED ❑ Distance to nearest: Well Foundation Property Line " SEEPAGE PITS ❑ Depth Size _ ✓ Number , SUMPS E1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ v. 1 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 Disdict. 'a.;`ti i Home owner or licensed agent's signatuia,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." Contractors 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 applicant must r all required inspections ompl rawing on reverse side. ® ��s Signed Title: Date: k OR EPARTI USE ONLY y ✓— Application Accepted by Date �r z Area 7� Pit or Grout Inspection by Date Final Inspection by Date Addition I Comments: y `�" 7� drtiv' _ - .1 ❑_.Stk 466-6781 ❑ Lodi A&3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 nn Applicant' Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, Stk., 5201 /df INFO FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT°N0. + (REV.110183)EH 7426