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f �- r APPLICATION FOR PERMIT' SAN JOAQUIN LOCAL HEALTH DISTRICT f" 1601 E. -HAZEL i ON A1lE.; STQCKTON, CA Telephone {209} 466-6781. �._ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .n (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. .. L I. . .� .d Job Address ?79 W �,IP City PM i I , Owner's NameAddressO [i • raj�f PhonF / // j Contractor • Address a4 Z ne 6K3_ i TYPE OF WELL/PUMP: - .NE- WELL SWELL REPLACEMENT DESTRUCTION �I PUMP.INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ � DISTANCE TO NEAREST:-SEPTIC TANk_ -tet SEWER LINES, DISPOSAL_FLD. _ _PROP. LINE FOUNDATION 's AGRICULTURE WELL `OTHER WELL___L__ PITS/SUMPS INTENDED"USE TYPE OF WELL PROBLEMAht6� CONSTRUCTION SPECIFICATIO it ❑ Innstrial ❑ 00 8gttom Ij Manteca Dia. of Well Excavation Dia. of Well Casing ;Domestic/Private ly'Gravel Packµ n Tracy ` i � 7ype of Casing L pecifications ❑ Public ❑ Other Qfrelta Depth of Grout Seal Type of Grout ❑ Irrigation Approx Depth ❑ ster Surface ea l Installed by Repair Work Done Type of Pump ` State Work Done Well Destruction Well Diameter « Se ng Material (top 50') Depth 'd ,,,.Or Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) s Installation will serve: Residence Commercial Ottier ` 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. ❑-40 "" '""" ^-""'" ' Method of Disposal Distance to nearest: Well Foundation Property Line' LEACHING LINE ❑__„No..&Length of line's Total length/size f FILTER19 D -Q ❑ Distance tcr-nearest: Well Foundation Property Line SEUAQE_PITS. '_❑ Depth ``� .Size, Number SUMPS ❑ Distance to nearest: Weir Foundation Property Line DISPOSAL PONDS ❑ 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 regula' s of the San Joaquin Local Health District. Home ow or liven 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 ny person in su manner as to becomes t to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifi the following:" . rtify tha in rfor nc of the work for which this permit is issued,I shall employ persons subject to workman's compensa- g tion ws of California ' ' The applicant cal `or all'r uir n c to a rse std 7 Sign Title: �-+ dAA Date: T FOR DEPARTMENT USE ONLY f] Application Accepted by Date t 2 ' rea v Pit or Grout Inspection by Date Final Inspection by /i l !/ !iv� Date - fy f Additional Comments: ❑ Stk 4664781 ❑ 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 j CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 5 + H 13-241REV.1/asl E ;.