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*401, APPLICATION FOR PERMIT N"O SAN JOAQUIN LOCAL HEALTH DISTRICT y— 3 ti I/`f 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.509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �/ Job Address �y s �jeW � City_SRX J rnC(ot Size PM Owner's Nam. RAi3nT Address yfL nrU R--,p Phone Contractor )L Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION O 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 Ll Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (-I Public FI Other F1 Delta Depth of Grout Seal Type of Grout _ I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done _ OQ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 \ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will e: Residence_ Commercial_ Other �. Number o/ living units. Number of bedrooms e11 Character of soil to a depth feet: r table depth C SEPTIC TANK ❑ Type/ Ca No. Compartments �I PKG. TREATMENT PLL ❑ Method of Disposal \ Distance to nearest: Foundation Property Line >` LEACHING LINE 0 ength of lines Total length/size MFILTER BED Distance to nearest: Well Foundati Property Line SEEPAGE PITS I I Depth Size Number SUMPS O Distance to nearest: Well Foundation Property line DISPOSAL PONDS Fl 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: "1 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 ust call for all required inspections. Complete drawing on reverse side. Signed X �.f[dA OiLA �SGI /`�–r'i Title: /� M��PP� Date: c' FOR DEPARTMENT USE ONLY Application Accepted by "� Date 1 z Area Pit or Grout Inspecti Date Final Inspection by Date Additional Comments: ❑ Stk t - Return ❑ Lodi 3fi9ronm a 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 FEH 1111.IREV 11.J EE NFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. � CF�-111