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{ APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CAS ,R Telephone 12091 466-6781 r 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. 186'2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address t. �* City Lot Size d PM iT7Owner's Name _,� Address Phone 4 Contractor dress icense No Phone C_j TYPE OF WELL/PUMP: NEW WELL- ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑\ - �° PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f :< _ I DISTANCE TO NEAREST: SEPTIC TANK l ,•'F( SEWER LINES DISPOSAL FLD. ti. PROP. LINE I FOUNDATION _. AGRICULTURE WELL OTHER WELL.'- PITS75UMPS I � INTENDED USE TYPE OF PROBLEM OBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial El Open Bottom } z R O-Manteca, Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tiacy Type of Casing Specifications ❑ Public 17 Other , ❑ Delta ` %Depth of Grout Seal Type of Grout ❑ Irrigation g --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of,Pump H.P. ' State Work Done Well Destruction,111 ❑ Well Diameter ` Sealing Material (top 501 �f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units:_L_ Number of be rooms ^'y ? ,4 I Character of soil to a depth of 3 feet: i Water table depth G SEPTIC TANK ❑ Type/Mfg Capacity ` No. Compartments E PKG. TREATMENT PLT. ❑ r t Method of Disposal Distance to riearest: Well Foundation s� Property Line ' 7W LEACHING LINE ❑ No. & Length of lines _ s� Total length/sizelQf ILTER B ❑ Distance to nearest: WellFoundation d4 d Property Line SEEPAGE PITS ❑ Depth d Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ : 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 dertifies the following."I certify thaf"in the'performahm'of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." l+ The applicant at c or requir pections. Co pl drawing an verse side. Signed7Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byG Date ' � Area 1 Pit or Grout Inspection by ,date Final Inspection by Date 4 43 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 83546385 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. + EH13-24lREV.i/e 51 �d EH t429