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5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " (Completein Triplicate) 4; 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 Ruies and Regulations of the San Joaquin Local Health District. Jr 4'• k �} "T 0l Job Address �, � � � City f fLot Size � v PM -Owner's Name 6f x/Y/f/8 r Address S �` �W 1 w ,�`� Fhone Contractor iV 00P Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth C1Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ,DESTRUCTION _CK iNo septic system permitted if public sewer is available within 200 feet) —_ Installation;will-serve:--Residence.— Commercial:_ Other_ Number of living units: Number of bedrooms r�I Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK ❑ Type/Mfg " Capacity No. Compartments PKG. TREATMENT PLT. 01. Method of Disposal Distance t'�nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS F ❑" Depth i Size Number r" (SUMPS' �. r+t " ❑ Distance to nearest: Well Foundation " Property Line kt DISPOSAL PONDS ,�AN ❑ 4, i ....... ...�hereby certify that i have pre_ _' �t-eapplication 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 i h manner to become subject to workman's compensation laws of.California."Contractor's hiring or sub-contracting signature certifies the folio g:"' certify t i the performance of the work for which this permit'is issued, I shall employ persons subject to workman's compensa- tion laws of C r l` P, The appli" all f I red ns. Complete drawing on reverse side. 1• I�� .. Date: S S Signed ! Title: FOR DEPARTMENT USE ONLY �^ ` Application Accepted by Date � "' Area Pit or Grout Inspection by Date t Final lnspection by cw� Date P ddition_al Comments:. �-., Q me-Aft S* 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 04 —� racjrk 835 6385 Applicant- Return all-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE .i AMOUNT REMLTTED CASH RECEIVED BY DATE PERMIT NO. INFO - 1J �.+ EH1'3 -70 rip EH 1426 10 2`SS