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vAPPLICATION FOR PERMIT I 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 cor ct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 185E for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,, yt,r Job Address iW cityR'-Lot Size PM �y IlL`��J"""• 1) Address %!` A/ fie Phone ^' Owner's Name [ ,rte A ! Contractor I '-,/( '¢� � Address//77�/l�t ' '�License No. J2(S Phone TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LMES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,Icandustrial ❑ Open Bottom ❑ ManteDia. 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 IrsaIled by Repair Work Done ❑ Type of Pump .L",1 H P Wo Well Destruction El Well Diameter Sealing Material (top 50'1 AI !aw Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic systemithin permitted blic sewer is G Installation will serve: Residence_ Commercial_ OtherNumber of living units:_ Number of bedroomsCharacter of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capac'rry No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispos Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines - - Total length/size FILTER BED - ❑ Distance to nearest: Well' Foundation Property Line, 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature canities 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 Favvs of California." Contractors hiring or subcontracting signature certifies the following:"I certify that in the berformance 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 gA11 fII required inspections. Complete drawing on rrav}� side- — Signed Kj � "n'__ Title: Date: 7 / )/ � FOR DEPARTMENT USE ONLY . .QI►�.* Date R Area 0& Application Accept oY Pit or Grout Inspection by I�A 01AData Final Inspection by pate /�0 b Additional Comments: ❑ Stk 4665781 ❑ Lodi 33621 ❑ 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 FEE RECEIVED BY DATEikPERMIT'NO INFO AMOUNT DUE AMOUNT REMITTED EH I' IaEV.i-em � -1 EH uai