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.4 w I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 >I 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/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. tf IO`j.20 ��SG Job Address City 0 Lot Size PM r Owner's Name Address /L10Y [ 6S Phone Cent r ��Qr� ,g"C'/'� ess_F0 &4st- _ License No,. �I66d _Phone9 =S 6p i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION le' SYSTEM REPAIR Mir OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE_ FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS` i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom LlManteca Dia. of Well Excavation Dia. of Well Casing W'/Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public Li Other ❑ Delta Depth of Grout Seal Type of Grout t i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump e_H.P. J ��- State Work Done P—MO lgla cine.4-t— 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depths Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence a Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments r r PKG. TREATMENT PLT. ❑ A Method of Disposal Distance to nearest: Well Foundation Property Line •I LEACHING LINE ❑ No. & Length of lines Total length/size I Q FILTER BED ❑ Distance td nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth •I Site _ Number "SUMPS-�i--— ❑—Distance toirreaiest:—Well'"""`"""""""Found`ati6fi'�""""i6p6rty Line DISPOSAL PONDS ❑ I 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. h 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." The applican1✓ t m t calf for all r wired inspections. Complete drawing on reverse side. `� Signed X Title: Date: l �0 T d I R DEPARTMENT USE ONLY y r Application Accepted by Date Area /7Z k Pit or Grout Inspection by Data Final Inspection Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95291 I FEE AMOUNT DUE AMOUNT REMITTED GSH RECEIVED BY DATE PERMIT'NO. INFO . EN3.241REV.rinse l � EH 14-2e L l l