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APPLICATION FOR PERMIT €"" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 .T i.t PERMIT EXPIRES 1 YEAR FROM DATE ISSUE[XigV4WbiVkIVN4. LI IHEALTH 3 (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / L DIE-4 R� -- City Q Lot Size PM t.� Owner's Name �idress _`.*S " 6 UA '7 Phone f > �,.. r Contractor VT/Q� ._ R F/P CAddress License No. Phone-364 TYPE OF WEL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ – OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing- 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout it Irrigation --Approx. Depth [,9 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of PumpH.P. 167, State Work Done + Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION H REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Weil Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line i SEEPAGE PITS f I Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A hereby-certify-that I-have.preparedthis-application and that the work will be done in accordance with San Joaquin county.ordinances,_stat laws, annd�� rules and regulations of the San Joaquin Local Health District. s 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: "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." I The applicant must call r all required inspections. Complete drawing o verse s' e I Signed X Title: � d� . Date: I ' R DEPARTMENT USE ONLY Applicatio Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by r Date �- Additional Comments: k ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT.REMITTED COt ASH RECEIVED BY DATE PERMIT NO. ► Rr. / " f EH 13-241REV.t/r 51 / ! I� EH 14-26 v ! 1 lr � .