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APPLICATION FOR PERMIT .. S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA U'�Mti Telephone (209) 466-6781 IPERMIT EXPIRES 1 YEAR FROM DATE ISSUED k`I (Complete in Triplicate) �"""�` ��b �• Application is heiehy 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. I i Sob Address r O �' ` Ya M 677--�[G ,V'"x &'� I �. Cityv Lot Size PM r v `Owner's Name 53, I A*/<_ Address i3�-Z S' law SZ�Phone { 0' i6 L�ontractor ��/ - Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 CONSTRUCTION SPECIFICATIONS Q ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public f7 Other C7 Delta Depth of Grout Seal T ' _ Type of Graut I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter''I Sealing Material (top 501 Depth Filler Material (Below 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION X INo septic system per if public sewer is availabie.,.withil"i 200 feet.) Installation will serve: Residence_F IGommercial_ Other Number of living units: Number'of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments 4 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'hearest: Well Foundation Property Line I SEEPAGE PITS i l Depth I Size Number + SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I] j 1 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- tion laws of California." The applicant must calf for all required inspections. Complete drawing on reverse side. Signed X Title: m Date: l/—42 1;�',9 fI R DEPARTMENT USE ONLY (� Application Accepted by CA AA DateArea 1 k q ! 224 Pit or Grout Inspection by Date Final Inspection by, Date 1 ~ 01 — I0 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621-1 ❑ 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 i INFO AMOUN/T�DUE AMOUNT {`REMITTED CiASH RECEIVED BY (LATE PERMIT'NO. EH 13-24 IRM i 55 EN 14-2e i� �