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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT !I 1601 E. HAZE00N AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 R tions of the San Joaquin Local Health District. 0 210 -zo AX4 �/09M, �i Job Address , "' City Lot Size PM i Ut X116 L;s(-; i Owner's Name Address Contractor Address d5,z r.�.r lP�,, IK Bu•License No. afo 813_Phone TYPE OF WELLIPUMP: U NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK .QIP SEWER LINES DISPOSAL FLDA01 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL .PFT SISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -' CONSTRUCTION SPECIFICATIONS �I` I--] Industrial- Ll Open Bottom Manteca Dia. of Well Excavation Dia'. of Well Casing ❑ Domestic/Private Gravel Pack ElTracy Type of Casing Specifi cations ,' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Awe• Type of Gro C Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) :I 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 I� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS C1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q 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. i 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 applic st call for require pections. Complete drawing o reverse si /7 �. Signed Title: ✓ Date: F R DEPAR ENT USE ONLY t �� Area Application Accepted Date 1/7 Pit or Grout lnspecti Date Final Inspection by YDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 „} Applicant- Return all copies to: Environmental Heakh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA-9 5201 4 FEET'AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI 'NO. INFO CASH + EH 13-24IREV.i/851 �/�.�� EH 1426