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M, "- ilk APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT /a 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p I (Complete in Triplicate) L 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. tv ' 33 1lob Address 7 N C_45A4 t__ Lot Size PM Xowner's Name `��"�' Addres � � Phon _ 1 "V• Contractor Address License No.'-' Phone { , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1Industrial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth- 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump i H.P. State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material {top 501 Depth t I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI N o septic system permitted if public sewer is 1 �l vailable 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 _ "� i Capacity— No. Compartments SEPTIC TANK ElType/Mfg Pa ty PKG. TREATMENT PLT. 1-1 -4- Method of Disposal Distance to nearest: Well Foundation Property Line ' Total len thlsize LEACHING LINE ❑ No. &'Length.of lines 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number _ SUMPS ❑ 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 District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance rn the work for which this permit is issued, I shall not s of California."Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's compensation law 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." l The applica ust call for all re uired inspections. Complete drawing on reverse side. Da \ esa�� .,�, te - �( -$7 Aigned Titiy. i FOR DEPARTMENT USE ONLY (f I Date 3- J �� Area 63 " Application Accepted by Pit or Grout Inspection by I to Final Inspy ° Date �4 Al ection b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO JJ�� + EH 13-24(REV.1/8 5) IZ-7 7 f £H 14-26 � p