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�. APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) lip 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 Regulation's'of,the San Joaquin Local Health District. Job Address ✓�� `. ty, Ci Lot Size iPM-3 € Owner's Name // G, Address I Phone Contractor �� ddre',s 4,nse No Phan' TYPE OF WELL/PUMP: NEW WELL EJ REPLACEMENT ❑ DESTRUCTION EJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications., O Public ❑ Other ❑ Delta Depth of Grout Seal- Type of Grout' E-Irrigation..,1 —L—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material,(top 50') b Depth Filler Ma[ehal iBelow 501 TYPE OF SEPTIC WORK:f NEW INSTALLATION V REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if.public sewer is available within 200 feet.) Installation will serve: Residence Commercial_„Other Number of living units:4— Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityQ No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal L nearest:Distance to Well L�fGFoundation_...� Fdation — Property Lined - � ei . LEACHING LINE No. & Length of lin`es - Total len gth/size - FILTER BED ❑ Distance to nearest: Well 0— Foundation t h Property Line i # SEEPAGE PITS ° Depth Size Number m P { SUMPS El Distance to nearest: Well /#1 Foundation Property Line DISPOSAL PONDS ❑ f 's 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. r -,4 c`x f • 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 m st c&Hor requir nspections. Com lete drawing on r verse side. Signed Xli sr Title: Date: u r FOR DEPARTMENT USE ONLY r Application Accepted by 0 Date W. Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: + i ( strF--466-6781 ❑ Lodi 369-3621 .❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH Q� 1+EH 13-24(REV.1/s5) � - U : /ZV4 EH 14-26 — w