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_ APPLICATION FOR PERMIT AN JOAQUIN LOCAL HEALTH DISTRICT ERIE COPY / 1601 E. HAZELFON AVE., STOCKTON, CA Telephone (209) 466-6781 t �ERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) App rc7tion 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 com fiance 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 Addreo '3� �a Sn /71D/�/PL rf City SL r`4f&XZ Lot Sue I ACL PM OwneesN l-/I CA/ het'- 6r1rWA1 Address -3YR lq&rleX lade Phone -0 ll, 3 3 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATIO ❑/ SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK / /�C SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 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 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is N' actable within 200 feet.) U� Installation will serve: Residence_ Commercial_ Other QQ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not l/ 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 applice ust ce11 for all7uir inspections. Complete drawing on reverse side. p ( v Signed X;".0 �li1-P�/ / 'Y�-� Title: ..—L:/ Date: ZJ""C a 7 6 FOR DEPARTMENT USE ONLY n Q' Application Accepted by Data_� Area `� O,_ Ph or Grout Inspection /by.1 tco , ate Final Innspection by DateAdditional Comments: tom" F�f w ��% i�r e C', ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE MOUNT REM AITTED CK�t RECEIVED BY DATE PERMIT'NO. a EH14&201REV.�,'esi �` c,z� EH 126