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._ Ir APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 0 (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 Sari 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. I` t!rl/l�J lrL t Job Address .� City of Size PM Owner's Name /1/,JLf /S Address 'T [_{ PhoneCa �'S �f —r— , Contractor.4 C�< S Address 1 ��-!+� , License No. � � Phone 3� TYPE OF,WELL/PUMP: NEW WE WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11' DISTANCE TO NEAREST: SEPTIC TANK SEWER DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIES/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI N5 C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p ' ' ations FI Public fl Other I Cl Delta Depth of Grout Seal Type of Grou I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction Cl Well Diameter Sealing Material (top 501 Depth I Filter Material {Below 50') _ ( TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIWADDITION ( I DESTRUCTION i {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 t Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ i Method of Disposal .Distance Ito nearest: Well Foundation Property Line t LEACHING LINE ❑,"tNo. & Length of lines Total length/size FILTER BED ❑ Distance Ito nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number 0 SUMPS. Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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." �I The applicant must call for all required" spections. Complete drawing on reverse side. Signed X Title: at r5 Date: .ir I FOR DEPARTMENT USE ONLY Application Accepted by Date i r Area Pit or Grout Inspection byII Date nn Final inspection by Dat �t `J Additional Comments: mer 44 �+'t- 4—'1. Stk 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 INFO AII DUE;i AMOUNT REMITTED CASH RECEIVED BY DATE �7 PERMIT ND. H t4-2tt(REV.t i n 51 3 I,