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k ' APPLICATION FOR PERMIT r1�i SAN JOAQUIN LOCAL IHEALTH DISTRICT 1601 E. HAZE' TON AVE., S I OCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES TYEARFFROM DATE ISSUED 1 1�EAL�ti1 (Complete in triplicate) >4�11I1R01�1�� ;ARV{CES '! 1i tiRi.+111I�E 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 cortipliance 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 dl ` " A �1 Job Address 01 � - -s Ir ) Cityy Lot Size PM Owner's Namedres§f` _70 E JJ Phone Lisa Contractor l; A ddfess � � Li.ense No. d A4�13Phone T �[3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION i, SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 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 i P'"Public f} Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump �� H.P. State Work Done &--- C2 19C(-5 -G-1 Well Destruction ❑ Well Diameter Sealing Material Itop 50') f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is I `" 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 1`1Capacity No. Compartments PkG. TREATMENT PLT. ❑ fi Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS D 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-Sam Joaquin.county ordinances-state laws,-and-: _ rules and regulations of the San Joaquin Local Health District. IM 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." 'I The applicant must call f all required inspections. Complete drawing on reverse side. i Signed X Title: Date: �+ l FOR DEPART ENT USE ONLY Application Accepted by Date 7 _ Area ! !" Pit or Grout Inspection by bate �1 Final Inspection by �t` Date Additional Comments: i) ❑ Stk 466-6781 ❑ Lodi 369-3621 U Manteca 623-7104 !171 Tracy 835-6385 Applicant - Return all copies to Environmental Health Permit/Services 1601 E!I. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. i r EH 13-24 IFiEV.I/n 51 eb �rvk e- EH 14-26