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r slow �- ;� - APPLICATION FOR PERMIT t f y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 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. Al- Job AddressA110- City � Lot Size �L/i� PM Owner's Name Address, ' s G ��chf aS� Phone Contractor, . Addres 1 License Not :Q-VZ.-Phone ` 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I 1 Irrigation --Approx. Depth l I Eastern Surface Seal installed by _ Repair Work Done C7 Type of Pump H.P, State Work Done_ _1 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is V I F 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 e0 No. Compartments � 14 PKG. TREATMENT PLT. ❑ Method of Disposal �! Distance to nearest: Well Foundation ail— Property Line szx� LEACHING LINE ❑ No. & Length of lines _ Total length/size (n '� FILTER BED ❑ Distance to nearest: Well Foundationa1 i Property Line i SEEPAGE PITS i I Depth Size + Number SUMPS LI 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. r 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 Cali ornia." q The applicant st call for all required inspections. Complete.drawing on r verse side. Signed X 4CE. Title: .tom Date: FM DEPARTMENT USE ONLY Application Accepted by Date r� Area Pit or Grout Inspection by Date _ Final Inspection by Date J� '16 0 Additional Comments: t< t e 1a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma eca 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 1FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦ E413-241REV.1/H51 �v C� � f EH 14-26, O r k