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Y3f� APPLICATION FOR PERMIT m� , d - � fl SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HA_ZELTON k VE. STOCKTON, CA Telephone 209y 466-6781 J 9q ;;:� c.. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVI,ROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hrertas'r+199IA 9d4APf %iication 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 ` City JrC-i I pt Size PM Owner's Nam Address r q �] Phone Contractor �� ss PO ` _` i[icens 71L?_ T 73one TYPE OF WELL/PUMP: NEW VALL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ; Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy y Jype of Casing I Specifications -1Public r Other $l Delta yy Depth of Grout Seal I Type of Grout I I Irrigation / _.Approx-0'6 I stern I Surf a Se'I Installed by I _ Repair Work Done C� Type of Pump H.p � State Work Done Well Destruction ❑ Well Diameter Sealing Madill 501 / Depth Filler Material aelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION-t4I (ftp septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commercial Other. 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ( r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS l I Depth Size Number# SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have re t pplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations the San Joaquin ocal Health Dist ict. Home owner or li sed agent's signature rtifies e f ing: " ify that in the performance of the work for which this permit is issued, I shall not employ,any par n in su nner as to ecome ub' o a s tom tion laws of California." Contractor's hiring or sub-contracting signature certifies the f owing: "1 cert y that I pert m h or or w ' perm) sued, I shall am loy persons subject to workman' ompensa- tion laws of aiifornia." The applic nt must c r d i o In on reverse Signed K e: 'FOR DEPARTMENT USE ONLY Application Accepted by � Date `'7 -�f'Z � Area4 ' Pit or Grout Inspection by Date Final Inspection by _ Date �v- Additional Comments: ❑ Silk 466-6781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y Q DATE PERMIT'NO. +.EH13.24 IREV,I/n5) F� EH t4-2(I