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`1� 3o A • 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. 000�� Job Address City Lot Size�- ' PM Owners Name -I1' <tii�7 Address Phone Contractor's Name No. Phone _ 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 x. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 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 Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 Q TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITIQ DESTRUCTION INo septic system permitted if public sewer is p 'S/ f1 available within 200 feet.) f� r Installation will serve: Residence_, Commercial_ Other �C Number of living units:---4— Number of bedrooms K Character of soil to a depth of 3 feet: ^ Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity ' Q(L No. Compartments " (� PKG. TREATMENT PLT. ❑ _ t � Method of Disposal Distance to nearest: Well. Foundation _L.! Property Line _ _. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 O 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 v' 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 call for II required inspections. Compl to drawing on r xr side. Signed N � Title:, �1/�l1 D. FOR DEPARTMENT USE ONLY Application Accepted by (i/� n Date �._G-f� u ) A x. pit-er6ront-laspectlon.by Date Final Inspection by [ (�L bIL• u,� hlt,n.../v` Date Additional Comments: ❑ Stk 4666781 ❑ 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 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO l 1r CASH . EH 13241R" 10/ail EH 1;