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f r APPLICATION FOR PERMIT PC V>Ep t SAN JOAQUIN LOCAL HEALTH DISTRICT R 1601 E. HAZEL T ON AVE., STOCKTON, CA SUL 1� ti I Telephohe {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAL HfcA�-SH NVIRONM�SERVICES ' . . !Complete in Triplicate) pERMI�� 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. E Job Address An City Lot Size PM t ;' 1+ Owner's Name Address A2 Phone 3 Contractor12dVil! Address • License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X ..- DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL FLD. PROP. LINE SEWER LINES FOUNDATION - �" AGRICULTURE WELL OTHER WELL -7 — PITS/SUMPS'` INTENDED USE TYPE OF WELL PROBLEM AREA EONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca :t Dia. of Well Excavation I L Domestic/Private ❑ Gravel Pack_ ❑ Trac Dia. of Well Casing Y Type of Casing Specifications M Public 17 Other [�! Delta ;Depth of Grout Seal I I Irrigation A Type of Grout I �- ppr, "iDepth I I Eastern Surface Seal Installed by 4 Repair Work Done Type of Pump H p t( f - { _ State Work Done { Well Destruction ❑ Well Diameter. Sealing Material (top 50') r r Depth Filler Material f8elow 5011 ff- 4- TYPE OF SEPTIC WORK: NEW INSTALLATION I.7 REPAlR/ADDITION 1.l {7ESTKUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence..` Commercial_ Other ' available within 200 feet.), Number of living units' Number of bedrooms f r Character of soil to a depth of 3 feet: „� SEPTIC TANK W iter table doptit_ ❑ Type/Mig't� - �! iF Ca acit # ' T ,. t P Y No. Compartments,,. ' ' PKG. TREATMENT PI-Tr li p.f Method of Disposal^ 's Distance to'nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines it ';° r Total length/size a FILTER BED ❑ Distance to nearest: ' Wellfl.j Foundation ' Property Line f�t-0 SEEPAGE PITS I I Depth 1 Size SUMPS v. Number L7 Distance to'nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ ' rules and regulations-of have San Joaquin Local tionHeaa Dr"that t. x o y 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 s the following employ "I ceiYify that in the performance of the work for which this permit is issued, I shalt not Home owner or licensed agent's signature certifie P Y an y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifiei 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 must call fo II re wired ins 4 # q pections. Complete drawing!64-X� Signed X a Title: Date: _ R-DEPARTMEl1lT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by } Da e� Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621.1 ❑ 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 INFO AMOUNT DUE AMOUNT.REMITTED CK RECEIVED'YD ATE �-, DATE( T��1SPr;.E1RMIT-NO. +.EH 13-24(REV.rirssl EH 10-2f] �^'L J'J� �_ `� trite t 1 3