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APPLICATION FOR PERMIT kk SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone !2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. 7 J 1 Job Address )-s� t{✓ r�LY' City• Lot Size /l 7 Owner's Name \ "'r� rl-ilE� Y✓ter` Address �5'S �) '"y I�''�'-"y �n -��" Phone {} -r.J�f �`K ( Phone. ContractQY-,.' ,, - �G-C __1, Address ! �• r i C �='� __License No.. �2- I - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LlSYSTEM REPAIR ❑ OTHER Z1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP.LINE .: FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑Industrial El Open Bottom ❑Manteca Dia.of Well Excavation Specifications f WCasing C3Domestic/Private 13 Gravel Pack El Tracy Type of Casing Specifications o ❑Public 71 Other 6 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 Dane Well Destruction ❑ Wel[Diameter Sealing Material Itop 501 c Depth Filler Material Meiow 501 TYPE OF SEPTIC WORK: NEW INSTAL T$ON 11REPAI IADOITION DESTRUCTION 0 (No septic system permitted if public sewer is Installation will serve: Residence� Commercial— Other available within 200 feel) Number of living units: / Number of bedrooms r �R Character of soil to a depth of 3 feet: -d Water table depth SEPTIC TANK 71 Typel Mfg Capacity No.Compartments PKG.TREATMENT PLT.❑ Method of Disposal [ Distance to.nearest: Well Foundation Property Line If f LEACHING LINE No.&Length of lines 2-S Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation -_ Property Line { SEEPAGE PITS ❑ Depth Sipe Number ' SUMPS ❑ Distance to nearest: Wel€ Foundation Property Line DISPOSAL PONDS O - I hereby certify that I have prepared this application and'ihat the work will be done in accordance with San Joaquin County ordinances,state laws,and rules and regulations of the San Joaquin Lecal Health District. Home owner or licensed agent's signature certifies the following:"I certity,that in the performance of the work for which this permit is issued,f shall not 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- Fz tion laws of California." The applicant st call for all rpquirroinspections.Complete drawing on reverse s Signed 7c �°j i-�.1./.yL Title: 'J r Date: FORD PARTMEN7 USE ONLY ` Application Accepted by �_�^","- g � - Date p "� Area � 1 iPit or Grout Inspection by Date Final Inspection by Additional Comments: 1 ❑Sik 466-6781 ❑Lodi 369-3621 ❑Manteca 823-7104 ❑Tracy 835-6385 Applicant-Return all copies to:Environmental Health Permit/Services 1601 E.Hazehon Ave.,P.O-Box 2009,Sik.,CA 95201 [FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Ff INFO F +EK 13241aEJ.i/a,l ''fib EH 14-28 w F! I ' Y i i r