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c APPLICATION FOR PERMIT P SAN JOAQUIN LOCAL HEALTH DISTRICT I� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 - 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 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. Job Address �• y City Lot Size PM h, OIL— Owner's Name Address Phone Contractor ess cense No. ? / Phone .� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ / DESTRUCTION ❑ �� . � PUMP INSTALLATION 111-1- SYSTEM REPAIR (6]/ OTHIT ❑ 4f DISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES �,� (� / DISPOSAL FLD.�Q_ PROP. LINE / FOUNDATION AGRICULTURE WELL / OTHER WELL PkTS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom F-1 Manteca Dia. of Well Excavation Dia. Dia. of Well Casing El Domestic/Private El Gravel Pack El Tracy Tracy Tyof Casing ��cc g Specifications MPublic F1Other F-1Delta Depth of Grout Seal �..—�' Type of Grout _ &4rigation ,?-O--Approx. Depth f I I Eastern Surface Seal Installed by _ Repair Work Done El Type of Pump • /H.P. /0 .P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth �,�� Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is 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: SEPTIC TANK ❑ Type/Mfg Capacity a PKG. TREATMENT PLT. ❑ od of Disposal Distance to nearest: Well Foundation Prop y Lir��_1089 LEACHING LINE ❑ No. & Length of lines Total length/ ' P,r FILTER BED ElDistance to nearest: Well Foundation Property LRWZlAlT 1�Z__2VICES SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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."Contractors hiring or sub-contracting signature rn 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 applic t t call f r all fired' spections. Complete drawing on verse 'de. Signed X Title:0 ov Date: "' 7r"--7 FOR EPA TMENT USE t7 IF ONLY ea �Application Accepted by Date Area 0 '2- s Pit or Grout Inspection by Date Final Inspection by� /� DatZ n��l_ Additional Comments: 2d_ ❑ Stk 466-6781 ❑ Lodi -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 IN O AMOUNT DUE AMOUNT REMITTED CK If CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24IREV.I/H5) EH 14.26 (VVJ