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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTjf 1601 E. HAZE T ON AVE., STOGKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENViROMENITAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work Ri"nKwaU I�#—C-i%plication 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 -Diisstrict. Job Address �l2na3 A-4 Cit t Size PM Owner's Name 7 ;f1w r'JLL:WAddress _ 1 n V. B( TT !�f'•1T��' Phone Coniractor - Address �. &---License No.4g�� 7 Phone ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 04 I`I Public C1 Other F1 Delta Depth of Grout Seal Type of Grout ! I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pumper H.P. J1_At.— State Work Done k Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 s TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION i l DESTRUCTION I )�1No septic system permitted if public sewer is -" /available within 200 feet.) y .Installation will serve: Residence'= Commercial— Other ' wNumber of living units: Number of bedrooms e Character of sol! to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments _ PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation ` Property Line >6 - LEACHING LINE ❑ No. & Length of linesTotal length/size FILTER BED ❑ 'Distance to nearest: Well ' `Foundation Property Line SEEPAGE PITS ti Depth Size :Number SUMPS i_l 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 accor$_ance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1(1. i 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 sutijact 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,1 shall employ persons subject to workman's compensa- tion laws of California." t 'The applicant mu of II required inspections. Complete drawing on reverse side. ,r Signed X � Tiile:, Date: _ P FOR TMENT USE ONLY Application Accepted by r Date C Area dv Pit or Grout Inspection by Date Final Inspection by A/2 Additional Comments: ❑ Stk 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 N INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE j/(�y� PERMIT,No. L y T U f/�^� C hJ L + EH 13-24(REV.t i H 5) EH 14-28 ` - "_ J y