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M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601'E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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. J b Address S f Cit Lot Size ,f®� L C7 0. PM 4--a-wner's Name Address Phone P I A *(l ray � �Eolltractor Addres License No. Phone_ �!/ TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAUTION SYSTEM REPAIR o OTHER o DISTANCE TO NEAREST: SEPTIC TANK M.'f SEWER LINES DISPOSAL ELD:� r PROP. LINE FOUNDATION f � AGRICULTURE WELL THER WELL PITS/SUMPS kyw, x INTENDED USE TYPE OF WELL PROBLE=M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑-Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing 10-Domestic!Private LQ�Gravel Pack ❑ Tracy Type of Casing_ + r Specifications f l Public ❑r Ter Cl Delta Depth of Grout Sealp:J` Type of Grout I I Irrigation /at L_l-Approx, Depth I I Eastern S dace Seal Installed by j Repair Work Done V Type of Pump _ �.i H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501, Depth l� Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIA DITION l 1 DESTRU TION l I (No septic system permitted if puNic sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of bedrooms Charas° r of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg f apacity No. Compartments PKG. T4ATMENT PLT. ❑ Method of Disposal Distance to Nearest: Well Foundatio 'Property Line # t� LEACHING LINE ❑ No. & Length of lines Total length/size s t „ FILTER BED ❑ Distance to nearest: Well Foundation Property Line `/1 SEEPAGE PITS I Depth Size mbar \ SUMPS Ll Distance to�earest: Well Foundation Property Line DISPOSAL_ PONDS Eli 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 Diltrict. 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, l shall not t v 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,1 shall employ persons subject to workman's compensa- tion laws of California." /The applicant must call for all req ' d ins ctions. Complete drawing on reverse side. V Silgedby Title: Date: d � rrrfff FOR DEPARTMENT USE ONLYADate Z Area Pit or Grout Inspection by Date+%�62 Final inspection by Date��'� Additional Comments: h ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH BY DATE PERMIT NO. INFO �. � EH 13-24(REV,tin5f to yv -�( EH 14-26