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4 APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,;PERMIT EXPIRES TYEAR FROM DATE ISSUED I IComplete in Triplicate) I 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District: Job Address City a Lot Size PM I Owner's Name 2e)hr 12f";_ l Address __._._—__ �-P i�� d Phone Contractor _ ddress License No.lrzPh ne TYPE OF WELL/PUMP: IQFW WELL ❑ _ WELL REPLACEMENT'❑"^" ""'DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL"FLO.: PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack!- ❑ Tracy Type of Casing AN M r - _ _Specifications' f`l Public (=1 Other_ 171 Delta Depth of Grout Seal r- � a Type of�Grout I I Irrigation _..Approx. Depth t I Eastern Surface Seal Installed by \ Repair Work Done El Type of Pump H,P. State Work Done _ � ; Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTI (No septic system permitted if public sewer is " __Pw� vailable within 200 feet.) V ' InstaAation will serve: Residence Commercial_ Other.' Number of living units: Number of bedrooms M t Character of soil to a depth of 3 feet: J Water table depth SEPTIC TANK ❑ Type/Mfg4 Capacity No. Compartments ^ PKG. TREATMENT PLT. ❑ } Method of Disposal Distance to;nearest: Well Foundation Property.Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance toinearest:—Well—'Foundation,"` "" ' ' Property Line h SEEPAGE PITS I I Depth I Size Number I SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ "1 4 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. 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,1 shall employ persons subject to workman's compensa- tion laws of California." f The applicgst ust; all for alE: tri spections. Complete drawing on reverse side. i * Signed X Title: 4 t Date: FOR DEPARTMENT USE ONLY1 19. 4 Application Accepte;�b - Date Area J Pit or Grout Inspectiy Date' 1r Final inspection by Oate Additional Comments: rINI ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104' 4' ❑ Tracy 63 63$5 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 CASH RECEIVED BY DATE PERMIT'NO. y � +..EH 13.24(REV,t/85) EH 14@e