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y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON 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 E 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. Job Address �r�/�/ C� :City Lot Size PM Owner's Name 1nDl 007(9 /"T�i ddress (i �ne� �l7''� Phone W06-537,'?7 Off+) Contractor Address License NoAg� 3 Phone F YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l , DISTANCE TO NEAR TIC.TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PAO EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, Excavation Dia. of Well Casing 3 Q ❑ Domestic/Private. ❑ Gravel Pack ❑ Trac Type of Casing Y YP 9 Specifications i Public Cl Other F1 pelta Depth of Grout Seal Type of Grout _ I I Irrigation —,_Approx. Depth I Eastern Surface Seal installed by Repair Work Done_❑ Type of Pump M.P. State Work Done " Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth _ Filler Material (Below 501 J r TYPE OF SEPTIC WORKc' NEW INSTALLATIOW1 I REPAIR/ADDITION f I DESTRUCTION. `(No septic system permitted if public sewer,is available within 200 feet.) Installation will sere:* Residence Commercial Other I Number of living units`j Number of bedrooms Character of,soil to t fe 3 a.depth.of- , e : a , � , ., ., ,. - Water table depth -. SEPTIC TANK$ f "❑ `Type/Mfg Capacity k>; NoCompartments PKG. TREATMENT f PLT. ❑ #`- ` ' f s Method of Disposal 3 f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines t Total length/size t "- FILTER BED ❑ Distance to nearest: Well Foundation Property Line E r 1 � SEEPAGE PITS I 1 Depth Size Number I l SUMPS ❑ Distance to nearest: Well Foundation f Property Line DISPOSAL PONDS ❑ i 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, ands rules and regulations of the San Joaquin Local Health Di§trict. 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." Contractors hiring or sub-contracting signaturer, 4x certifies the following: "I certify that in the performance of the work for which thisY Persons permit is issued, I shall employ -r Y tion laws of P subject to workman's comp8nsa-� The applicant must call for required inspections. Complete drawing on rete side, r I �( Signed X _ TitIO t--fff J r__Q N/7'1,[lCi Date:'�'3'�9' FOR DEPARTMENT USE ONLY Application Acceptedby date -'"" Area Y Pit or Grout Inspection by Date Final Inspection by Date v Additional Comments: ❑ Stk 466-67$1 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CH RECEIVED BY DATE PERMIT'NO. ♦.'EH 13.21(FIEV.11 rs51