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I. APPLICATION FOR PERMIT �5 ; ; SAN JOADUIN LOCAL HEALTH DISTRICT Y �_ ' = 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 W `— r PERMIT EXPIRES TYEAR FROM DATE ISSUED `I (Complete in Triplicate) I Application is hereby made to the Sari 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. .I Job Address -5 ✓�~ ` r ��i —'City, Lot Size PM Owner's Name r �' -- Address �� Phone �c.� Addres I License No. 3 Q Phonek`9-19 a Contractor TYPE OF WELL/PUMP: ;,NEW WELL L1WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INS ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ c DISTANCE TO NEAREST: SEPTIC 7ANK SEWER LINES DISPOSAL FLO. PROP. LINE (` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other 11 Delta Depth of Grout Seal Type of Grout — i I Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by - t Repair Work Done ❑ Type of Pump H.P. State Work Done r r Well Destruction ❑ Well Diameter Sealing Material (top 50') .z Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 teet.l Installation-'will serve: Residence"_ Commercial_ Other Number of living units: Number of bedrooms H Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k K PKG. TREATMENT PLT. ❑. 1.1 Method of Disposal ' Distance to nearest: Well Foundation Property.l_ine I LEACHING LINE ❑ No. & Length of lines F Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number } SUMPS 0 Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS 0 f L 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- x tion laws of California." The applicant must call jor all required inspections. Complete drawing on reverse side. `- Ir 011 owe Date: .signed .rifle: _ FOR DEPARTMENT USE ONLY Application Accepted by Date f r� Area Pit or Grout Inspection by Date Final Inspection by Date 2 Additional Comments: 7 _-s 02, G V41,C_ LL `r c& (A-"ti ' L"- 4,�,, �(-9`11 ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 &0—e-eL Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., PA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT*NO. INFO +.EH13-244REV.1/H5) I�444 EH t4-M C0 e�