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�v APPLICATION FOR PERMITsr SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA KMI kAJ (�4,+vu� , Telephone (209) 466-6781 N o PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) IOU e 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 4� G-y-�.ity of Size PM Owner's Na n Address ��f, l�a'!h"�� /11�- _...,-, Phone 0 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS u f INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS N 0 Industrial O Open Bottom ❑ Ma Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications fl Public ❑ Othe 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _._Approx. Depth l 1 Eastern Surface Seal Installed by _ f Repair Work Do Type of Pump H.P. - State Work-Done Well D coon ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIRIADDITION i I DESTRUCTION iNo septic system permitted if public sewer is E, available within 200 feet.) Installation will serve: Residence J Commercial_ Other ` ^` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r 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 r� SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance.to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E . 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. 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 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." Th applicant mus all for all r ' ired i pp pections. Complete drawing on reverse �side. Signed X Title: 11`�1r�1 /�� _— Date: Xl�_Z OR 7ARTMENT USE ONLY Application Accepted byat � �n++ Date \A Area G' Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �Y ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 847 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE INFO AMOUNT DUE I AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO- EH 13-24(REV.I/H51 r�oi9'1U 17 EH 14-2e l,(/ �--`�4