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APPLICATION FOR PERMIT +; SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA M Telephone (209) 466-6781 a, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)x, ,; JF . 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin h Local Health District. . �• :r 'i Job Address Re?t/ Ci Lot Size Gt.tA&L &) PM Owner's Name Addressaq9ao Phone Contractor's Nam License No. aG Phone T— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'❑--'"""""""`'"SYSTEM REPAIR'f]' """"` """OTHER'❑ y ff DISTANCE TO NEAREST:,SEPTIC'TANK_ SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } r INTENDED USE TYPE OF WELL_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ,f f ❑ Industrial ❑ Open Bottom .❑,Manteca Dia. of Well Excavation Dia. of Well Casing-- I ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specificationsi 0-i Ik ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r � ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of PUMP1 H.P. r� State Work Done .� Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth 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.) FInstallation will serve: Residence Commercial Other t e, = t r Number of living units:--_L— Number of roo Y41 F f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK RYType/Mfg Capacity No. Compartments ' k PKG. TREATMENT PLT. ❑ f _11..Method of Deposal A Eh I Distance to nearest: Well �sQ Foundations Property Line ;V' _ 40 LEACHING LINE �No. & Length of lines f Total length/size FILTER BED ❑ Distance to nearest: Well Foundation f ?_. T� Property Line k S � SEEPAGE PITS l��-_Depth _Size l umber # '' SUMPS ❑ Distance to nearest: Well Foundation I'Property Line DISPOSAL PONDS ❑ t , I hereby certify that I have prepared this application and that the work will be done in accoFdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 7 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,-1 shall not employ any person in such manner as to become subject to workman's compensation laws of,Cairf_ornia." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman'srcompensa- tion laws of California." The applicanust call for r ired inspections. Complete drawing on reverse side. i Signed Title: P Date: 0 [ FOR DEPARTMENT USE ONLY I r t i I - Application Accepted-by - -._.- ._ �_....._. Date AM�O Area Pit or Grout Inspection by Date in Ins ction by Date? V e� j Additional Comments: 7/4) 3[ 1,00 `, # ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca WY7104 _ ❑ Trac i Applicant-Return all copies to: Environmental Health Permit/Services TW1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � (FEE NEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 1&24(REV.10)831 .� , a� �/'! rt, EH 1426 ' ` 5