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APPLICATION FOR PERMIT 9"1 �1��-�"-L_. II SAN JOAQU€N LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA `- p Tekephorle {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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. IIS Job Address. City Lot Size PM yOwner's Name � nfiGkess -_ Phon H /\ r Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-D-- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE Ilk FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public n Other ❑ Delta Depth of Grout Seal Type of Grout k I I Irrigation --,Approx. Depth I i Eastern Surface Seal Installed by - Repair Work Done ❑ Type of•Pump H.P. State Work Done—f - Well Destruction ❑ Well,Diameter Sealing Material Itop 50 ! Depth Filler Material IBelow 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION 1 l DESTRUCTION (No septic system permitted if public sewer is Il available within 200 feet.) Installation will serve: Residence Commercial_ Other ~ Number of living units: Number of bedrooms i Character of soil to a depth 1 f 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments PKG, TREATMENT PLT. ❑ ' Method of Disposal Ih pistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "1 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: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." Il The a licant must call for all required in pections. Complete drawing on reverse side. s Signed Title: t)h1 ,_� �1�� ate: f _ i FQR DEPARTMENT USE ONLY Application Accepted by I Date 'f 3` AreaCm (� Pit or Grout Inspection by Date Final Inspection by Date . Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952001 !i Rf�-�Glfp,�IP�� FEEAMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT No. CS INFO s - S� a.fH 13-241t7EV.r/K51 EH 1428 II