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38S APPLICATION FOR PERMIT 407 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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. Job Address /D Z—. f City Lot Size PM Owner's Name v' /W / Address hone IV i l Contractor Address d License No.*' Y/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Db)K&VA'F!:?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 ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 i 1`1 Public [=] Other # ❑ Delta Depth of Grout Seal I Type of Grout I I Irrigation --Approx. Depth 1 1 a ternrface Seal Installed by Repair Work Done ❑ Type of Pump' H,P. State Work Done 6/4.LI G/ f Well Destruction ❑ Well Diameterr Sealing Material (top 501 I O Depth Filler Material (Below 50') - i ! TYPE OF SFPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION l I DESTRUCTION l 1 INo septicjsyster�., ermitted if public sewer is t 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(d�epth ! SEPTIC TANK EJType/Mfg# Capacity No. Compartrhents j PKG. TREATMENT PLT. El � Method oisposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ z 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. 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 f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring orlsub-contracting signature certifies the following: "I certify that in the plrformanceof-tFfiework f61r wh` tCAN,is permit is issued, I shall employ ipersons subject to workman's compensa- tion laws of California." i nN11 The applicant requir �s.tGterli" eta drawing on reet 'e side. Signed X Title: i Date: h/ l 1 FOR DEPARTMENT USE ON ' i Application Accepted by �� Data _ ______ - _ Area I Pit or Grout Inspection by Date Final Inspection by I Date Additional ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _— i FEE INFO AMOUNT DUE i AMOUNT REMITTED CA RECEIVED 6Y DATE PERMIT'NO. +.EH 13-24IREV.liw51 �S--Qo ; �� —/ ! EH 14-29 I