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II APPLICATION FOR PERMIT I �i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11 (Complete in Triplicate) ' Application is hereby made to thn e 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. HI Job Address I' t City Lot Size -PM ffie Owner's Name Address Phone II + ;: Contract 4 Address License No.3asaa(A Phone 6 TYPE OF WELL/PUMP: 1! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION"❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `�f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy x .Type of Casing Specifications I I'1 Public n Other 1. .,_- ❑ Delta Depth of Grout Seal Type of Grout ` I I Irrigation !Approx. Depth ! I Eastern Surface Seal Installed=by Repair Work Done ❑ Type of Pump � x H.P. §tate Work Done _ y Well Destruction ❑ -Well Diameter Sealing Material (top 501 v r. 4 Depth -Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U }DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) T w Installation will serve."Re§idence�_X-4Commercial��'. ther Number of living units: Nuitiber of .e rooms R= a :.(-'-*, .r�, _ ,�'.'.' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANKf Type/Mfg I Capacity�� No. Compartments .,.MPKG. TREATMENT PLT. ❑ �`� / r / Method of Disposal Distance to nearest: Well ,Foundation=_�� Property.Line LEACHING LINE No" & Length of lines Total.lengthlsize FILTER BED ❑ Distance to nearest: Well 160 Foundation'-1 Property Line�- �. " -SEEPAGE PITS Depth � Size � n "" F - Vumher i x SUMPS' ❑ Distance to nearest: Well LA _ Foundation 1_0 Property Line DISPOSAL PONDS ❑ �. " 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, an 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,t shall employ persons subject to workman's compensa- tion laws of California." 11 The applicant mu call for =pections. Complete drawing on reverse sid Signed X Title: �• a Date: II FOR DEPARTMENT USE ONLY 7 Application Accepted by J1211e _ Date !7_ � 9 Area Z,,� z&or Grout Inspection by Dana Final Inspection by�� J Date c Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 89 104 ❑ Tracy" 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r r FEE AMOUNT DUE AMOUNT REMITTED r RECEIVED BY DATE PERMIT ND. INFO ♦.EH 1324IREV.t/n51 © F l�j Ot -1/ Q S- , {P EH 14-29 ?