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APPLICATION FOR PERMIT s� 3t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED E (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 weli/pump and the Rules and Regulations of the San Joaquin Local Health District. CityQ10 Lot Size PM Job Address Owner's Name ' ` ! Address Phone Contractor 44ikti Address �I z � License No.?e— /�46LO_-Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 Y CONSTRUCTION SPECIFICATIONS ❑ Industrial' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public I7 Otheri ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _,-Approx. Depth l I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ' Filler Material IBelow 50')-- (� TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION f I' DESTRUCTIO l (No septic system permitted it public sewer is � i available within 200 feet.) Installation will.serve: Residence s) Commercial_ Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet vWater tabic depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 _ r k . . „` k I r Method of Disposal " 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 1 SEEPAGE PITS C I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and 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'taws of California."Contractor's hiring or sub-contracting signature certifies the"a o "I ertify 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 lif is ` The applicant u f r all required inspections. Complete drawing onreverse sid . Signed Title: � . . ..- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area I Pit or Grout Inspectio ' Date Final.Inspection by G 1 Date {� r y z 1 �� Additional Comma , - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 - a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 PC S FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. INFO J/� �j Q +.-EH 1324 1Rev.i i x 57 + ! /�!/ !! (/(/'�vf�0 EH 14-26' I.