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�.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 / r / L `�c� City Lot Size PM Owner's Name �.i.� /��-- _/ I, �2 Phone ti Contractor dress / I icense Np! Phone lam" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ ODen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications ("I Public ❑ Other FI Delta Depth of Grout Seal Type of Grout_ _ 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 ❑ Well Diameter Sealing Material Itop 501 . Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: —4-- Number of bedrooms_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg iL_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method oL Disposal Distance to nearest: Well/©0 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well(on Foundation�— Property Line _ SEEPAGE PITS 11 Depth Size Number cisMP LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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." q The applicant ��st�caylyf all�/q—m ill ins ect`rons. CompI I it g gr�,r'verse side. ^ f Signed X o rT��;r/��'c-Q.� Title: ,�L-L��, (�_',� Date: FOR DEPARTMENT USE ONLY Application Accepted by Lrl 11pp Date -� Area Pit or Grout Ins ( lJ �� Inspection by Date Final Inspection by Date kclitional Comments: 1� Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH I n , 13, y . EH 11i�IREV.irn51 90 , I IA _ V 2(� �� 7-i' EH u�m VWWV��_