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M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZE T ON AVE., STOCKTO CA Telephone (209) 466-67$1 M' PERMIT EXPIRES 1-YEAR FROM DA EC (Complete in Triplicate) APR 9 Application is he+eby made to the San Joaquin Local Health District for a permit to constru � `�a11 tb ork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for�w'e117dtir�r6�� a �Aultimns of the San Joaquin i Local Health District. PER mi� 1ISER 'ICES Job Address I fC�[ (% 1,r � .-� rt - City Sr,(< Lot Size PM f Q Owner's Name r dress �� 4 d KIM I �� "' �1 , - Phone Contractor!� Address ka License No/4 `�]�� Phon " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ,SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO !NEAREST: SEPTIC TANK SEWER.LINES !4 DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL + OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom (71Manteca Dia. of Well Excavation Dia. of Well Casing G!•Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cawing Specifications ('1 Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout - I I Irrigation .Approx. Depttv I 1 Eastern Surface Seul Installed by Repair' 'Work Done D- Type of Pump•, H.P. State Work Done— } Well Destruction ❑ Well Diameter \ Sealing Material (top 501 i r p Depth Filler Material-•(.Below 501) -- TYPE OF SEPTIC WORK: NEW INSTALLATIONN1.! ' EPAIWADDITION i I iDESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) r " Installation will serve: Residence_ Commercial" Other Number of living units: Number of bedro s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT. ❑ "'} Method of Disposal f Distance to nearest: Well Fodndation Property Line LEACHING LINE ❑ No. Length vi lines - Total,length/size.' FILTER BED ❑ Distance to nearest: Well Fourifda-tion =property=Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 'r I hereby certify that I have prepared this application and that the work will rbe•done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di%trict. 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 whicWthis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantMust call for ail re ired inspections. Complete drawing on reverse side. } 9 !� Signed X �7itle: /!�'7=!/ - -- Date: �^ FOR DEPARTMENT USE ONLY Application Accepted by �Y)" x J Oate "'f- )! - U Area 1 D t Pit or Grout Inspection by Date � Fina! Inspection by Date 't f r Additional Comments: F1 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 f FEE AMOUNT DUE AMOUNT REMITTED CAS4i RECEIVED BY DATE PERMIT NO. INFO 1�,[ +.EH 13-24(REV.4iN5) CJ g� EH 14-26