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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON"AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED n ate ', N �`�► K� - MM (Complete tri Tr.ipficatel / Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install LLL///he ork 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. I1 o (o(3 Qf r 4 t �/ _ + v Job Addresss rt �" ; /• �1 r✓ ty'r�{ Lot Si e� '9C.X +`{4 -Owner's Name Address �� /,t ' , Phone 1V Contractor AddressvLc9 /J �L� License Na4 , Phone TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT`❑ DESTRUCTION ❑ PUMP INSTALLATION er—j SYSTEM REPAIR ❑ OTHER ❑ # DISTANCE TO NEAREST: SEPTIC TANK WER LINES ""�_ D SPOSAL FLO. PROP. LINE / Y' FOUNDATION AGRICULTURE WELL ��THER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFiCATIO i ❑ Industrial A-AperrBottom 1-1 Manteca Dia. of Well Excavation Dia. of Well Casing 4-B2westic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5pecificatians / r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal lt* Type rout ❑ Irrigation --4pproxt Depth ❑ stern Surface Seal Installed by 72 {` Repair Work Done ❑ Type of Pump -r H.P. State Work Done r E Well Destruction ❑ Well Diameter Sealing Material {top 501 4 Depth IFiller Material (Below 50'1 I b TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -� i available within 200 feet.) Q i installation will serve: Residence Commercial_ Other S. Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth w- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lrie . rr � —LEACHING LINE ❑ No. & Length of lines s 'Total length/size T 1� FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! SEEPAGE PITS ❑ Depth A Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line `2r`' DISPOSAL PONDS ❑ XI 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 m a r all required inspections. Co a drawing on reverse side. Signed r �ril �' f _„.�. Title: _ Date: y �---�"`� FOR DEPARTMENT USE ONLY � V. r Application Accepted by r � Date Z' Area ` Pit or Grout"inspection by Da Final Inspection by `J Date r . Additional_Comments: I ❑ Sik--=466-6781 .1 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 F Applicant, Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 FEE INFO CASH DUE AMOUNT REMITTED CASH REeeCEII/V11ED BY DATE _ PERMIT'NO. .a + EH13-24(PI EV.i/esu i EH 1 -26 VVV - 1 YY P d