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! APPLICATION FOR PERMIT 'I SAN JOAQUIN LOCAL HEALTH DISTRICT 'I 1601 E. HAZELTON AVE., STOCKTON, CA S " ��Tele hone 209) 466-6781 II �i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED7 AUG 311 X9 3 fI° (Complete in Triplicate) PP Y t q p f bwWQML,.�T AL.TH Application is hereb made to the San Joaquin Local Health District for permit to construct and/or'install the l application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rulammay��l iia�'a an Joaquin Local Health District. Job Address�S d a [�`-�z� I'a/"1.�, City Lot Size PM Owner's Name." �/e"� rC'u!:Ii! Address,�asb U Phone Contractor Address License NoA6 ii�� Phone7,_,`�lq TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial 0 Open Bottom ❑ Manteca pia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public f7 Other Ll Delta Depth of Grout Seal Type of Grout _ I I Irrigation !1-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done be Type of PumpT �, H.P. �4 State Work Done_ Well Destruction ❑ Wdf Diameter Sealing Material (top 501 c Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 , REPAIR/ADDITION l I DESTRUCTION ! I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial Y_.Cather Number of living units: i L Number of bedrooms Character of soil to a depth of 3 feet: { Warer table depth 1 SEPTIC TANK ❑f Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑r yl�jt #,w Method of Disposal Distance to nearest: Well Foundation Property Line r jI LEACHING LINE 0:1 No. $ Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .i4 SEEPAGE PITS I'I Depth Size Number SUMPS Ll, Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑'. it 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 mariner 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." 11 ` The applicant sic I for all eq 'ed inspections. Complete drawing on arse side. ,may Signed X tle: Date: II FOR DEPARTMENT USE ONLY ` Application Accepted by Date 'J Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: li # ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. +. EN 13-24[REV.t i H 5) EFI 14-3e