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APPLICATION FOR PERMIT �Z7� SAN JOAQUIN LOCAL HEALTH DISTRICT 3601 E:.H,4ZE,L T ON�ArVE., STOCKTON, CA Telephone (209)'466-6781 4 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 workLhiNki"tW`rb`Jk isdl�&T# is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules andtFj! I f1Pyb9RWG&0oaquin Local Health District. Jab Address City t Size PM Owner's ame Address� 210;"D W /Phone 4731 46' Ir OF Contractor ddress 8 License No.0 6 3 73 phone TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public M ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I.1 Irrigation � Approx. Deptft ,I•1 Epstein Surface Seal installed by _ Repair Work Done U--�Type of Pump �`�' H.P. State Work Done t r �. Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) s, Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms 2 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK _ ❑ Type/Mfg Capacity No. Compartments ) PKG. TREATMENT•-PLT 0• Method of Disposal Distance to nearest: Well Foundation Property Line j 41 LEACHING.LINE Ll—" e, r.Ygi�,6 t Lenkgth of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line J SEEPAGE PITS Size, Number, SUMPS L� Distance to nearest: Well Foundation w Property Line EJ 1 ' DISPOSAL PONDS .�� '•� � ` !, "'� rz 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 r i rules and regulations of the San Joaquin Local Health District. Home owner d 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 a person in su h manner as to become ct to workman's compensation laws of California." Contractor's hiring or sub contracting signature I card ie a fallowing: "1 a ify that in th pe or an a the work for which this rmit is issued, I shall employ persons subject to workman's compensa- dtion l s of Cah ornia ' The piicant /cell/f r all re uir s. C p ate drawing on re �1a side. Signe X v Title: �/ y `�/J _ _ Date: . FOR DEPARTMENT USE ONLY �1 ! Application Accepted by Date Area a } [J Pit or Grout Inspection by Date - Final Inspection by � jf Date O' l � Additional Comments: i ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT-NO. +.EH 1324 IREV.t/x 57