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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 p9 RY39 r 1601 E. HAZELTON AVE., STOCKT.ON, CA 6 � � Ilk Telephone (209) 466-6781 F E B 2 U Snn1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUER VIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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. 1062 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7 �-{.� / /C�ily i�yr. /"1" Slze - PM Owner's Name V' f e ` '�113 Addressw �, '1'P�hhone Contractor 'v Address f� �G "'r-�"'� License No/-�/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom Cl Manteca �. Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public n Other ❑ Delta Depth of Grout Seal Type of Grout_ _ I I Irrigation --Approx. Dep I Eastern Surface Seal Installed by. - Repair Work Done 13' Type of Pump ,H.P, State Work Done / Well Destruction ❑ Well Diameter {SeaIng Material (top 501 Depths t- •� =Fillel.Material-(below-509 — TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR AADDITION I. DESTRUCTION 1 I INo septic system permitted if public sewer is , available within 200 feet.) f Installation will serve: Residence_ Commercial_ Other r ( i1L I Number of living units: _ (dumber of bedrooms I 'r Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK ❑ Type/Mfg I rr Capacity No- Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ( Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines I Total length/size (�—f FILTER BED ❑ Distance to nearest: Well { Foundation Property Line SEEPAGE PITS I I Depth Size I Number SUMPS U Distance to nearest: Well ( Foundation Property Line DISPOSAL PONOS ❑ r 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 Dibuict. I 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." Contractoes hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." ' The applicant st c II far ell r wired inspectio . Complete-7draw ing onreverseside. �� 1 signed X le: cyst A/+� / Date: �9d �� / R DEPARTMENT USE ONLY / 1 G,y//�6f/` Application Accepted by s"'e Date `� Area - Pit or Grout Inspection by Date ,Final Inspection by, Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 23M, Stk., CA 95201 l FEE AMOUNT DUE AMOUNT REMITTED CA6H RECEIVED BY DATE PERMIT N0. INFO . EH 13-24(REV.rr x sl EH 1429