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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZELTON AVE., STOCKTON, CA • Telephone (209) 466-6781 A� 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) ENV1rR,0��iNAE '7'1l iR! ATH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des rued his application is made in compliance with SanJoaquin County Ordinance No.549.tor sewage or No. 1862 for we11/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address �_DC)Q City Lot Size PM Owner's Name '� Address Phone ont ctar Wr !;s �r ,�,,��/ License Na.�Z -Phone ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAID OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE __. _::. s FOUNDATION__ _ _AGRICULTURE WELL _OTHER.WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom EJManteca Dia. of Well Excavation Dia. of Well Casing j >CQgmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public Cl Other Ll Delta Depth of Grout.Seal Type of Grout _ I I Irrigation _..Approx. Dept j�I,Eastern Surface Seal Installed'by _ Repair Work Done k Type of Pump /"! H.P. It State Work Done Well Destruction ❑ Well Diameter/ Sealing Material (top 50') t" .......Filler-Material-(Below-50'-1- TYPE OF SEPTIC WORK: y=W INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: r Residence_ Commercial , ),. Other Number of living units: Number of-1 bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity �r _ # _ No. Compartments PKG. TREATMENT PLT:❑ �'`�'' -.1 Method of Disposal I > Distance to nearest: Well Fob undation kk^ ^ Property Line LEACHING LINE !❑ No. 8r Length of lines Total length/size FILTER 'BED ❑ Distance to nearest: Well fFoundation r Property Line SEEPAGE PITS I 1 Depth Size '' tNumber SUMPS Ll Distance to nearest: Well A-4- Foundation•--t 'r-""'-i'roperty Line DISPOSAL PONDS I❑ 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 Diltrict. 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 California.": The applicant must,call for Il quired insppctions. Complete drawing on rev se side. r Signed �j� a' f'l1f � .__ Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date Area 2/ Pit or Grout Inspection by Date Final Inspection by Date✓ Additional Comments: Ih ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f+' Applicant - Return all copies to: Environmental Health Permit/-Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. , +.E11 1324 1REV.F i x 5] _Z�, f EH 1428 S/ �Q `�,3�.{�p l r