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1W Il. APPLICATION FOR PERMIT ppYMENT . SAN JOAQUIN LOCAL HEALTH DISTRICT RE C;Fk VES. 1601 E. HAZEL T ON AVE., STOCKTON, CA oR a 1988 Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED tqVI�0NMENTAL HEALTH (Complete in Triplicate) pERM1TISERVICES 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. Job Address of '�32 3 k;, e City Lot Size PM Owner's Name &M5 Address PIT. r ' Phone 832—Z205- Contractor 2 r Address ansa No._�P h a n e C5Y�r� TYPE OF WELL/PUMP:V NEW WELL WELL REPLACEM NT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1 SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. f PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing Domestic/Private )6 Gravel Pack )d Tracy Type of Casing PSpecifications fl Public n Other 171 Delta Depth of Grout Seal T pe pf Grout I I Irrigation �-Approx, Depth I I Eastern Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ! 1 REPAIR/ADDITION l 1 DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms x Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 l I Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L] 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 Disfrict. 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." Contractors 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 Cal ornia." The applica ust call for all requi inspections. Co plata drawing on r er side. Signed X Title: i ate: R DEPARTfiME USE ONLY Application Accepted by 7 Date Area C SCS Pit Gro Inspection by Date�f r - Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY PATE PERMIT NO. INFO CASH ♦ EH 1 3-24 IREv.1/H 5) dr EH t4-2B