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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 FIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in,'Triplicate) 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. y✓� . L.' Job AddreCity Ldt Size PM ss- �� ' - Owner's Narrfer -k+ Address PhorW / a Contractor �/ Address tl, '01&1Z14 License No. 1' Phone TYPE OF WELL/PUMP: N . WELL ❑ WELL REPLACEMENT L1 DESTRUCTION ❑ PUMP INSTALLATION 0/ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISP05AL 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 racy Type of Casing Specifications 17 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout =- 1I Irrigation Approx. Depth1 Eastern 5 ace e I 1 stalled by Repair Work Done ❑ Type of Pu �� 'y� H.P. mp State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 - -- Depth ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION t 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve-, Residence Commercial— Other 1 Number of living units: Number of bedrooms Character-of rsoil to a depth of 3 feet:� Water table depth SEPTIC TANK I O 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 I 1 Depth 1 Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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. Hofne.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." 4 The applicant must call for Il required inspections. Complete drawing on reverse side. _ � �/�� Signed -Title: ' Dater /�— •FOR DEPARTMENT USE ONLY �f j Application Accepted by • Date b3/f 2— Area �"�-[`6 Pit or Grout Inspection by Date Final Inspection by Date . 71 Additional Comments: ❑'Stk 466-6781 ❑ Lodi 369-3621 0 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 CK RECEIVED BY DATE PERMI7'NO. INFO to 7 � +.EH 13-24 IREV.1/x 5J �}t� r y p�L 4?/23/f2 `"067-3 EH 14-213