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, APPLICATION FOR PERMIT SAN JOAQ!OCAL HEALTH DISTRICT III " L 1601 E. HAZE IT ON AVE., STOCK-TON, G Telephone (2091 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules'and`Riiiulations of the San Joaquin Local Health District. Job Address City ize PM E Owner's Name Address �. Phone Contractor ��. 1+� Address l f 6��Q License No Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR �K' OTHER ❑ 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 4 ❑ Industrial ❑ Open Bottom-_.. ❑ Manteca --Dia. of-Welt Excavati(5n- - Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f ❑°Public ❑ Other a`❑'.Delta Depth of Grout Seal Type of Grout 1 ❑•Irrigation's --Approx. Dept Eastern Ice Seal Installed by t Repair Work Dane Type of Pump H.P �- - State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 1r f' Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION O,—REPAIR/ADDITION Ll DESTRUCTION L1INo septic system permitted if public sewer is 1 * -tl _ available within 200 feet.) Installation will serve: Residence Commercial_/Other -9 x Number of living units: Number of bedrooms Character of_soil to a depth of 3 feet: ` { Water table depth k SEPTIC TANK ` ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal �1 Distance;to nearest: Well Foundation Property Line � r LEACHING LINE,s ❑H No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation Property Line . I SEEPAGE PITS•-•.Vr ❑ Depth I Size Number SUMPS ❑ Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS Fi Thereby 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 ap i t m t call for all r ired in ction omplete drawing verse side. Signed X Title: J!!, � Date: FOR DEPARTMENT USE ONLY l Application Accepted by Date ' Area i J ila Pit or Grout Inspection b Date Final Inspection by Datq/ _ I i I 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 f n r .i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASHX' t + EW 13-24 1REV,1H 51 / EHt 4-29