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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTOCSR ) n G� Telephone (209) 466-6781 3f� PERMIT EXPIRES 1 YEAR FROM DATE IAI P q4 J (Complete in Triplicate) Application is haieby made to the San Joaquin Local Health District for a permit to construct an otr t i_T „� tion is made in compliance with San Joaquin County Ordina ce No. 549 for sewage or No. 1862 for well/I urrtRules and Reguytirns of the San Joaquin Local Health District- ��'111111 TT}}�r{{ �722 V 1 / 7 Job Address City Lot Size PM Owner's Name _ AX ss > � ;'Phone 76 12 Contractor_ 4-Y dress 0J License No,/ i•ld Phone�7 / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAUblEINT 17 DESTRUCTION ❑v PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWS LINES DISPOSAL FLO. PROP. LINE FOUNDATION _ AGRIC LTUR ELL OTHER WELL PITS/SUMPS (— INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom _ ❑ Mante Dia. of Well Excavation_ Dia. of Well CSsing r. ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing 'Specifications ❑ Public Cl Other alta Depth of Grout Seal Type of Grout__ i I Irrigation _,Appro><, Depth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump _ H . State Work Done _ Well Destruction C Well Diameter Sdahng Material (top FJYl Depth— Faller Material (BeloW 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 41r REPAIR/ADDITION I ' DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence— Commercial V'0�Other Number of living units: Number of bedrooms Character of soil to a depth of 3 flet- Water table depth _ SEPTIC TANK ❑ Type/Mfg _ Capacity No, Compartments PKG. TREATMENT PLT. ❑ y L Method of Di osal _ Distance to nearest: Well ! fi ' oundation Property Line . _� — !CNI it a 11 Ly LEACHING LINE i-7 No. & Length of lines J _ 'i length/size FILTER BED CJ Distance to nearest: Well _1 oundation _ Property Line I 1 Depth Size_-_ _ bar _ a,GE)IPITS Distance to nearest: Wefl oundation —� Property LineAL PONDS C] I hereby certify that 1 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 Joaouin Local Health District. J 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 Contracto's hiring or sub-contracting signature certifies the following: "I certify t'nat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California The applicant st call!f =2Z��=rawing on reverse Side. Signed X Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date I Pit or Grout Inspection by _ Date Final Inspection by Date.'/ © K Additionrf Comments: __ r - ❑ Stk 466-6781 1-1Lodi 369 3621 10 Manteca BM-71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P-0. Box YEE 5,000D1oS1 �// INFO AMOUNT DUE AMOU REMITTED CK RECEIVEDE50AEH 13-21(REV.iiMSi / EM 11-26