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..li i L) APPLICATION FOR'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. .HAZELTON 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/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. t. I' Job Address FJ 17'1 -city l a{ot Size PM II ��/ � �S~'�c� ,p f� ,r�y Owner's Named �C 1� ress �'L / L� t} � 1'- C � i' rphone ~�J / �I Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELIeW 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 CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Irrigation _Approx. Depth ElEastern �Sf' a Seal Installed by Repair Work Don•e b L Type.of Pump ._ H.P. PF State Work Done_.,, Well Destruction ❑ Well Diameter Sealing Material (top 50'1 `i I ,Depth Filler Material (Below 50') r)Ls-) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAiR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial—_ Other �..��.. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -- Y Water table depth SEPTIC TANK .DT e/Mf -� = Yp 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑•L' .: 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 SEEPAGE PITS ❑ Depth Size Number t �❑ Distance.to nearest: Well - - ..Foundation. Property-Line DISPOSAL PONDS ❑ . k(, Thereby 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."Contractors 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 applica ust c for all r red i pections. Complete drawing on reverse side. Signed t 1' ' Title --. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area ✓ Pit or Grout Inspection by Date FinalInspection by Date Additional Comments: ❑ 5tk 466781 ❑ Lodi 369-3621 anteca 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 C INFO RECEIVED BY DATE PERMIT NO. + EH13.24 iREV.10/831 EH 1428 -EZ1� _ � S � � 1d