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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT ), 1601 E. HAZEL T ON 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3 e,671 ` TCity 576l_K 4Lot Size PM Owner's Name r j e) Address 3 �1 ��-�� Rb Phone �t l Contractor_ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTfON PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done C Well Destruction ❑ Well Diameter Sealing Materialrltop 501 I Depth - Filler-Material(Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADOITION 13 DESTRUCTION I I (No septic system permitted if public sewer is f ' available within 200 feet.) Installation will e: Residence— Commercial_ Other Number of living units. Number of bedrooms r Character of soil to a depth o feet: I er table depth SEPTIC TANK ❑ T e/M YP � Ca _ No. Compartments [ PKG. TREATMENT PLT. El3 Method of Disposal C Distance to nearest: Foundation Property Line LEACHING LINE ❑ ength of lines Total length/size FILTER BED 11 Distance to nearest ' Well Foundati Property Line SEEPAGE PITS 11 Depth Size..`---- Number r SUMPS 0 Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS 0 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, 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 call for all required inspections. Complete drawing on reverse side. -,..Signed X ,�- Date: lZ3—�'2 FOR DEPARTMENT USE ONLY ^ I Application Accepted by Date "' Area Pit or Grout Inspecti Date Final Inspection by Date �Z Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 p Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.Q. Box 2009, Stk.,.CA 95201 E t FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'No. 4 INFO + EH 13-24 MEV.1 i H 5) EH 14-28 -•�