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APPLICATION FOR PERMIT Z79 SAN JOAQUIN,LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA 1 ut.�xD Telephone (209) 466-67$3 moo .' Owuu. PERMIT EXPIRESµI YEAR FROM DATE.ISSUED Mo ists: (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 Lgcal Health District'" . Job Address City s. Loi Size SX 13 s D PMG3 Owner's Name S Address `�Q - QO R fic, Phone Contractor e{Q( ' License Na.r29_'i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC {A ❑ Industrial ❑ Open Bottom ❑ Manteca 4 Dia. of Well Exca Dia. of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type sing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth stern Surface Seal Installed by Repair Work Done ❑ Type of Pum H.P. State Work Done Well Destruction ❑ We meter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units- Number of bedrooms �1 Character of soil to a dpt of 3 feet:.� Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ . I . 1 i~ f Method of Disposal .I Distance to nearest: Well Foundation Property Line 1 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ` Size Number SUMPS ❑ Distance to nearest: Well 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 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's 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 California." r The applica t call for all requireinspections. Complete drawing on reve se sid . li Signed X # Title: Date: 4 FOR DEPARTMENT USE ONLY O Application Accepted by Date _DL Area Date Final Inspection by Rl � Date ` Inspection Additional Comme Pit or Grout nts: ` d ❑ Stk 466-6781 ❑ Lodi 369-362'110 Ma_nteca 823 7104 ❑ Tracy 835-6385 F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE _ AMOUNT DUE �J. AMOUNT REMITTED RECEIVED-8Y INFO CASH DATE PERMI7'NO. + EH13-24(REV.>795) �'r�