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APPLICATION FOR PERMIT F . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate). Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ritade 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. 1'r---1 Job Address City Srlll' Lot Size PM_ { Owner's Name MaRla- Address g2Za® �� c.rr. f Phone t _, _ y1 t Contractor's Name /0ZP/�igiUSi�7 .P (,License;lVo. ��1 Phone TYPE OF WELL/PUMP: NEW,WELLN❑ I'`i 1 jWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP`iNSTAL-tPi-TiON•-i Rr� L�-STEM-REP-AIR�Q - -- - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE ,----M-,..,.—FOUNDATION _- _ AGRICULTURE WELL OTHER WELL PITS/SUMPS .. . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E9 Industrial ❑ Open Bottoml ❑ Manteca, a . -Dia'of,W611,Ex� cavation t ' La., of Well Casing f El Domestic/Private ❑ Gravel Pack ❑ Tracy , R Type of-Casing specifications Public �' `. ❑ Other t ❑ Delta a Depth'ofGi ut•Seal� f Type of Grout O Irrigation _�ppiox;Depth ❑ Easterrf S rface Seal Installed by I l Repair Work-Done—[DType of-Pump— H:P.- 7 State Woraone 1p p� � Well Destruction ❑ Well Diameter Sealing Material (top 501 l a��10K41 .B Depth Filler Material Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION L) (No septic systdmA'pormitted if public sewer is I a4lable withiiw.200�feet.) Installation will serve: Residence_ Commercial_ Other ``'l Z% Number of living units: Number of bedrooms J Character of soil tQ a depth of 3 feet: Water tab/depth ' G SEPTIC TANK 11Type/Mfg Capacity No. Compartment`s• PKG. TREATMENT PLT. ❑ IIMethod oii' Dispyyosal i Distance to nearest: Well Foundation Property Line: LEACHING LINE ❑ No. & Length of lines Total length/ ize ! i FILTER BED ❑ Distance to nearest: Well Foundation Property Line; 1 SEEPAGE PITS f ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line f ; DISPOSAL PONDS ❑ � 1 hereby certify that I have prepared this application and that the work will be done in accordance with SaIn Joaquin county ordinances, state laws, and f1 rules and regulations of the San Joaquin Local Health District. t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which/his permit is issued, I shall not It employ any person in such manner as to become subject to workman's compensation laws of California." dontractors 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 Orsdns dubject to workman's compensa- tion laws of California." The applicant t Zall r r inspections. Complete-a awing-on-reverse side. ' Signed X Title: Date: /FOR DEPARTMENT USE ONLY Application Accepted by Date Area 2 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 a. 0 Manteca 823-7104 ❑ Tracy 835-6385 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box ., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED 13H RECEIVED BY DATE PERMIT"NO. INFO q + EH 13-24(REV.10m) - ' —7f EH 14-28