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r; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' IComplete 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. jr y Job Address 3; '.'>�� + CitLot Size_ � PM Owner's Name - �4 Address Phone Contractor.� �`c Address__R/ z !;-/ I idAil License No.,aQ� Phone r 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 ❑ Industria��,�', „❑IOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ©Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other �-�-�-0 Delta----Depth-of Grout Seal— � "' -Tj of Grout ❑ Irrigations ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dohe ❑ 'Type of Pump H,P. State WorktDone �' r Well Destruction ❑ Well Diameter ` •Sealing.Material (top 501 4"{ Depth Filler Material !Below 501 ' I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer i I e f ./ available within 200 feet.) 1 Installation will serve: Residence! Commercial r! Other A y ' Number of living units: Numberof-bedroa s �` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK , ❑ Tyre/Mfg A) -- ; �1U No. Compartments �— PKG. TREATMENT PLT. ❑ a �' 1 Method of ++Diryrysosal "• Distance to nearest: Well foundation 1010f Property Line A�� LEACHING LINE 9?"'No. &,Length of'iines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation} 4 ' Property Line _ n SEEPAGE PITS ❑ Depths - Size ` - f Number f SUMPS [?"'Distance to.nearest: Well YJ Foundation •_->�.P "Property Line 1 DISPOSAL PONDS ❑ ', 1 c M" �pJ;� -- - r moi, 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 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 Cal'ifor'nia." ' " `� - . The applicant must.cal for a required nspeetions. Complete drawing on reverse side. Signed ^_ -tyr � w ' Title: A�—v Date: " . FOR DEPARTMENT USE ONLY Application Accepted by. t Date vIWArea fJ -Pit or Grout Inspection by Date Final.lnspection by Date4D j 4 f I Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621- ❑ Manteca 823.7104__.[7 Tracy__835�385 � — Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CKO INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. I + EH13.24 MEV.l/a 5) f 5 EH 1428 �.� 1%1_ M ,.