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APPLICATION FOR PERMIT E SAN JOAQUI.N LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA $ Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (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. i� City Lot Size PM lob Address ' (O' WAO ')'�ddress. 0�11ex Owner's Nam - Phone ' e ' ' �� C �`Contracta �� i -Addres License N l Phon TYPE OF WELLlPUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l - PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C1 r PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w ❑ Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private L1 Gravel Pack EI Tracy Type of Casing Specifications 171 Public F1 Other 171 Delta Depth of Grout Seal Type of Grout i. I 1 Irrigation —.Approx.,Depth 4 1 Eastern Surface Seal Installed by Repair Work Done © Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 t TYPE OF SEPTIC WORK: NEW INSTALLATION'I l REPAIR/ADDITION l i DESTRUCTION (No septic system m permitted if public sewer is Stvailable Installation will serve: Residence Commercial — Other Number of living units: Number of bedrooms c' Character of soil to a depth of 3 feet: t .01 Water tattle depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments F'F PKG. TREATMENT PLT. ❑ s '` Method of Disposal - f: Distance to nearest: Well f ""Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS f l Depth, Size Number t SUMPS Ll Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ rk will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the wo rules and regulations of the San Joaquin Local Health District. I 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 appli nt must call for a I required inspections. Complete drawing on reverse side. Title: �_j _ Date/-.A3-4t2 FOR DEPARTMENT USE ONLY ^^�� Application Accepted by DateV— Area ia A Pit or Grout Inspection by Date Final Inspection by Date >'_1 / r Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 y FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DAT> PERMIT NO. INFO + cI +,N 13-241REV.I IH 5) 5r0p 135,00 `1 b EH 14-28 .-