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4 APPLICATION FOR PERMIT _ t N JOAQUIN LOCAL HEALTH DISTRICT E 11601 E. HAA-E,', 04 AVE., STOCKTON, CA r Y` Telephone (269) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) UVIROtViENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein is 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 T r —Q0.�© City t Size PM 3' Owner's Name ddress / Phone Contracto Address License No. Z' 7 Phone TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT ❑_/ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR P' OTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r�� INTENDED USE.. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + �S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of GfBut I I Irrigatian /_Approx. Depth/i I Ea tern Surface Seal Installed by l Repair Work Done V Type of Pump ca � � H.P. ! State Work Done' Well Destruction ❑ Well Diameter Sealing Material atop 661 Depth '�--�Fi IerdMaterial .Below 50') - TYPE OF SEPTIC WO—NEW INSTALLATION 11 REPAIR/ADDITION ll CiLSTRUCT10Nf'I'I-(Tl6'septic'systern'pefmitied if public sewer is s. available within 200 feet.l Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: + f k I Water tattle depth SEPTIC TANK ❑ Type/Mfg Capacity s No. Compartments, PKG. TREATMENT PLT. ❑ '��--� •�� ^�, Method of Disposal Distance to nearest: Well Foundation- r Property Line Y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line l I SEEPAGE PITS I I Depth Sire Number l SUMPS ❑ Distance to nearest: Well Foundation Property 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 regulatioSan Joaquin Local Health Di§tfict. Home owner Icense d agen signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any arson insuch man r as to become subject workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th following: "I certify at in the or anc f wo ich this permit is issued,I shall employ persons subject to workman's compansa- tion laws f Californi The appli ant $t all re ire C plet e cawing on side Signed X Title: Date: F R DEPARTMENT USE ONLY Application Accepted b Date Area Pit or Grout Inspection by Date Final Inspection by Date «/Z" V�. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 CK RECEIVED BY DATE PERMIT'NO. INFO CASH w,EH 13-24 IREV.t/K!5) EH 14-2e