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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT z 1601 E. HAZE ON AVE., STOCKTON, CA 1 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 Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. , Job Address E?,3" v` ©�ff / r City tot Size PM_ I r Owner's Name Md)10t F 97 V Address SZ i��7 '�- Phone �A � Contractor 1 '� Address ,.� thl' License No,3 99110 Phone � `�+ i TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. LINE r FOUNDATION AGRICULTURE WELL OT L PITS/SUMPS INTENDED USE. TYPE OF WELL r.,P_ROBLEM-AREA_-CONS N SPECIF_ICATION,S� ❑ Industrial 0 !Gravel pen Bottom ❑ Manteca ia. of Well Excavation { Dia. of Well Casing ❑ Domestic/Private ❑ Pack cy Type of Casing Specifications M Public ❑ ther ❑ Delta Depth of Grout Seal I Type of Grout I I Irrigation __ pprox. Depth 1 1 Eastern. Surface Seal Installed by c Repair Work Done ❑ Type of Pump t ~�H�.P.'. State Work Done _ Well Destruction ❑ Well Diameter Sealing'Material (top 50') -- Depth Filler Material-(Below 50') TYPE-OF-SEP-TIC WORK: `,NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION INo septic system permitted if public sewer is �� available within 200 feet.) Installation will serve: Residence_ Commercial Other i I 1 Number of living units, Number of bedrooms Character of soil to a depth of 3 feet: I - > ` i Water table depth" I SEPTIC TANK ❑ Type/Mfg t Capacity ! No. Compartments PKG. TREATMENT PLT. ❑ fI Method of Disposal Distance to nearest: Well--Fc d t' Property Line I � � t LEACHING LINE ❑ No. & Length of Iines Total length/size FILTER RED ❑ Distance to nearest: Well Foundation Property,Line VVV SEEPAGE PITS I I Depth Size Number • SUMPS ❑ Oistance to nearest: w Well r` Foundation - _ Property,Line DISPOSAL PONDS ❑ ; r 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 District. 1 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-sribject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfortnance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 9 The applicant must call for all required i ppections. Complete drawing on reverse side. Signed X Title: �� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date93lom Alrea , Pit or Grout Inspection by Date Finai Inspect on by Date Additional Comments: � r 1 ❑ Stk 466-6781 ❑ Lodi -36210 Manteca 823-7104 ❑Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 CK 4FEEI INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT_NO. +-EH 13-24IREV.t/n51 ll l EH 14-26 �'�� 0