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APPLICATION FOR PERMIT 3L �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT 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/of 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. Job Address City Lot Size PM Owner's Name ., Address �4-(�+�.�? Phone0a T143 Contractor ddress 5 nse No Phoner/�� ` TYPE OF WELL/P MP: NEW WELL LJ 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 r'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout --- I I Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by t _ Repair Work Done ❑ Type of Pump H,P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION V, REPAIR/ADDITION l 1 DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence VI"� Commercial T Other Number of living units: _J_ Number of bedrooms--A.Character of soil to a depth of 3 feet: �' Water table depth J SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ t r Method offDisp'os9k Distance to nearest: Well Foundations Property Line ^z, LEACHING LINE ❑ No. & Length of lines ✓�✓ Total length/size FILTER BED ❑ Distance to nearest: Well 100 Foundations_ Property Line 9 SEEPAGE PITS 11 Depth f A N-wylber SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state4ni rules and regulations of the San Joaquin Local Health Di'�trict. 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, 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: '9 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 us f Wrquired pe tions. Complete dr ing on reverse side. 79 Signed X Title: Date: GlY FOR DEPARTMENT USE ONLY Application Accepted by Date Area l Pit or Grout Inspection by ate ! s1 Final Inspection bv Data 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, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT ND. SH + EH 13-24 JREV.1/N 5) 0 UU �EH 14-28