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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Ply Telephone (209) 466-6781 PER_MI_T_E_XPIRES 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. _0, yam_ `" Cit Lot Size PM Job Address 1416'W Owner's Name �� W4, Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION U 5)�STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ty-. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL '�n. ' 1OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'7 Public-�`4L Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation ----Aprrox. Depth I 1 Eastern Surface Seal Installed by---- Repair y_ _Repair Work Done 0 Type of Pump^H.P. State Work Done Well Destruction El Diameter Sealing atenal_ttop 50') Depth Filler Material (Below_5011_ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is avaiiable,within 200 feet-) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: T Water table depth. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal v Distance to nearest: Well F-ouAdation Property Line LEACHING LINE ❑ No. 8 Length of lines w i Tptal length/size FILTER BED 0Distance to nearest: I Well�_et Foundation / Property Line S .�--- SEEPAGE PITS I I Depth I Size J Number SUMPS r Ll Distance to nearest Well 'Foundation Property Line DISPOSAL PONDS D I hereby certify that I have prepared this application and that the work will be d¢ne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health DiWict. II -�—Home owner or licensed agent's signature certifies thJ following: "I certify that in the performance of the work for which this permit is issued, I shall not rl employ any person in such manner as to become subj4ct-to-w©rkfnarrs-cempensation 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 Califo The applicant u cal for allre fired inspections. Complete drawing on reverse side. igne X _ Title: ._ Date: r FOR D A MENT USE ONLY r t'.. 77 Application Accepted by Date _ Area �y r ' T 9 Pit or Grbut Inspection by \ -�' -----rDate Final Inspection by Date /7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 366,-3621 0 Manteca '823-7164 ❑ Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED—' CASH RECEIVED BY 'PATE PERMIT �N,0n./� . EH13-24-IREV-�✓.+t.r.l �D-rp� '. EH t4-26 III LLL