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{ _ APPLICATION FOR PERMIT' SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON AVE., STOCKTON, CA A 1 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+n=compl[anee'viiith San`Joaqu+ri County Oldinanca No ,549:for-sewage or No. 1862 for welltpump and the Rules and Regulations of the San Joaquin Local Health District;y� i ti - 'rYi Job Address City_ Ta Lot Size PM Owner's Name _ Address 3/�SV- / Phone Contractor Address &-?r �qhvk ense No. Phone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT X DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR L] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 76-, SEWER LINES DISPOSAL FLD.�S!ZR PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 70 '_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private `d Gravel Pack X Tracy Type of Casing l'" VG Specifications (`l Public 11 Other Ll Delta Depth of Grout Seal ft�"h` �T�yp�eoff,Gro�j i I Irrigation .-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑_ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f.I REPAIR/ADOITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to 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 11 Depth Size _ Number SUMPS L-] Distance to nearest: Well _ Foundation a Property Line DISPOSAL-PONDS-. .❑ -- w.. — - - - w. _ I hereby certify that i have prepared this application and that the work will be done in accoidance 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 lawsjofCafornia." The app) ust call for all requirecrispections. Comple drawing on re ers si e. Signed X ide: Date: /a��Y✓ F9 DEPARTMENT USE ONLY / Application Accepted by Date Lo r 3ft Area Pit r Gr t Inspection by Date/ am incl Inspection by 4A Additional Comments: F, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA r pR�N 1,988 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH CK It RECEIVED BY DATE PE ►7Y Q ate , �� 3 s 1)7y +.EH 13-24[REV.+i K sY EH 14-28