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.J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 M0C-A (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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. `5-a4� Job Address S0 je. f G,CQ,_O� *1 City Lot Size PM Owner's Name Address?" / O -RLI- 01-t AIlW Lf,' Phone Contractor's Name., y. License No. / A-3 7 3 Phone36 , V - TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ gyp' PUMP INSTALLATION ❑ SYSTEM REPAIR ff OTHER ❑ l 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 n ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout 2 rrigation ---Approx. Depth F1 Eastern Surface Seal Installed by— JARepair Work Done E: Type of Pump H.P. a State Work Dane 1 S Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material'(Below 501 fD v-TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_y_._ 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 F PKG. TREATMENT PLT. ❑ 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 SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ 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: "I certify that in the performance of the work for which this permit is issued, I shall not j employ any person in such manner as to become subject to workman's compensation laws of California.-Contractoes hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californ" ." The applicant m all r all re inspections. ompletee drawing ev�rse side. ^� Signed ! 'title: Date: /y) FOR DEPARTMENT USE ONLY �i Application Accepted by "// d-7� Date 5 �C— `f Area Pit or Grout Inspection by Date� � Final Inspection-by G`''am/ Date Additional Comments: ❑ Stk 4666781 ❑ 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 i FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'N0. i + EH 13 U 24(REV.10183] (5 C_h(� 5(tli—�U ��,/ •�Q3 EH 14 I 1 1