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Y i APPLICATION FOR PERMIT D SAN JOAQUIN LOCAL HEALTH DISTRICT ,T +•8 1601 E. HAZE T ON AVE., STOCKTON, CA Ata . Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E4.�NVIRc'n�' -f Rl.. (Complete in Triplicate) PERlviI1/6F-Kv1�irS, 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 1 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. I Job Address City:� Lot Size PM Owner's Name cod Address _�„�� Phone Rz � Contraclo Address�d !to 664164:1 � License N 3/G 4�2_ Phone TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,=JNTENDED USE ,TV.RE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Al. O-Pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications41, Public n Other R Delta Depth of Grout Seal Type of Grout I I Irrigation ,'��.Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Typ`of Pump H.P. State Work Dane .o Well Destruction ❑ Wei I Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is 1 1 i available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: I� Number of bedrooms Character of soil to a depth 11 f 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No�Compartments PKG. TREATMENT PLT. ❑ 1`. Method of Disposal ))Distance to nearest: Well Foundation Property.Line �F LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED. ❑ ''Distance to nearest: Well Foundation Property Line SEEPAGE PITS I S (Depth Size Number SUMPS L) !'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ;I�, d hereby certify that I have prepared this application and that the work will be dohe 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'i compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cert `y 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." II i The applicant must for all re ired il5pestieas. Complete drawing o reverse side. Signed l Titl Date:v�� k +T OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by II� Date Final Inspection by �' Dateipj Additional Comments: I!I ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies Nto : Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rK J� EE AMO(�UNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO, INF+.EH1321tREV.tie51 r] $ � 00+��•/�! EH 11.2a _-