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F1APPLICATION FOR PERMIT '` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;TON AVE_ STOCKTON, CA Telephone (209) 466-6781 �r`rrl/�fl�y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f,'' (Complete in Triplicate) Application is he,eby 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 Sart Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and ilia Rules and Regulations of the San Joaquin # Local Health District. Job Address fJ 'S ity Lot Size PM _ V-SCI PPG Cv.� Owner's Name ! Address P�4 Phone 011 Contract � �' Address 'L*cense No.4� a- Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS YA,lIndust6al ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic I Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications F. Public Fl Other {-1 Delta Depth of Grout Seal Type of Grout I I trrigation Approx. Depth I I Eastern Surtacu Seal installed by Repair Work Done X Type of Pump_4+A. t=+ H.P. 01"-- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') F, Depth Filler Material (Below 581 _ \ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) C 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 \ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` 'I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number ' SUMPS L_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C.1 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 �I 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 t c for all required inspections. Complete drawing on reverse side. Signed X Title: C Date: FO EPA_RITMEN_T USE ONLY � Application Accepted by Date �i Pit or Grout Inspection by Data Final Inspection by ffA/ ate Z Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO. EH 13-24IREV.I/h51 EH 14-2e f " r