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! 2. APPLICATION FOR PERMIT 7 : 1 ItV I-F SAN JOAQUIN LOCAL HEALTH DISTRICT � � 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVtRCVENTAL HEALTH F ERM11/SERVICES 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 Nom. 5J9 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health district. � ' (�} [nJ -7)5`G-p 4-C-4.-,-"; �} n L3j—?-,o U-os' Job Address City-, Lot Size PM Owner's Name J' C- �Y.t't��_-_ Address' Phone Contrat:tor ! Address �- License No)X13 7�Phone k16 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP AI 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing Specifications f-1 Public Cl Other. C] Delta Depth of Grout Seal Type of Grout _. I I irrigation —,.ApproxDepth I I Eastern Surface Seal Installed by (� Repair Work done El Type of Pum., R y H.P. State Work done �— Well Destruction ❑ Well Diameter Sealing Material (top 50') , a Depth � Filler Material (Below 501 s TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION { I DESTRUCTION i I (No'septic system permitted it public sewer is TMr available within 200 feet.I installation will serve: Residence___:7�_ Commercial— Other - ,' i 4 r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I y Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity^ r� _ No. Compartments PKG. TREATMENT PLT. D R Method of.Disposal, YDistance to nearest: Well Foundation Property Line ` LEACHING LINE ❑ No. & Len th of lines - 9 Tota[ length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line j SEEPAGE PITS I I Depth t Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D J} 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 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." The applicant st call for all required inspections. Complete drawing on reverse side, r Signed X ills: Date: PARTMENT USE ONLY 1 Application Accepted by Date �' Area r s Pit or Grout Inspection by Date Final Inspection by Dat o Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE A NT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT"No. + EH13-24{REV,t/n 5) Ll EH t4-ZB