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. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.; STOCKTON, CA Telephone (209) 466-6781 *�� 1 6X988 F PERMIT EXPIRES 1YEAR FROM DATE ISSUED I~NVIROMEIVTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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. ` Job Address 9 g �a�W_/ City Lot Size PM + U * Owner's Name Address 7 3 t7 194tfO!A� Phone ` 0-1 � i Coritractor JDAfji� 0.��Fr/ Address �� License fVe,/ 1 3 3 Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 1iDESTRUCTION C]PUMP INSTALLATION L1SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (DIndustrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications I �. I'l Public n Other_ ' j Cl Delta Depth of Grout Seal Type of Grout !rl'irri anon - Approx�:.t7e I ! Eastern Siiiiace Seal-lnsialled Repair Work Done [ Type of Pump H,P. �Q State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted it public sewer is available within 200 feet.) _sery on w at installiill e: Residence_ Commercial Other '# ' 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: F Water table depth i - SEPTIC TANK ❑ Type/Mfgi Capacity-7L— No. Compartments PKG. TREATMENT PLT. Cl 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth I Size T Number SUMPS ❑ Distance to neatest: Well foundation Property Line DISPOSAL BONDS ❑ w 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, ancj� rules and regulations of the San Joaquin Local Health District. 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 subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signaturiL 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."The applicant st ca for all re it inspections. Complete drawing on reverse side. Date: Signed X RD) P TMENT USE ONLY rki' Application Accepted b _date Area Pit or Grout Inspection by Date Final inspection by Date �� Additional Comments- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 4 FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO aL-4 + EH 13-24(REV.I i H ss 3 i EH 14-28 t