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, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (i✓d / kred� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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. e� Job Address � � ,J Ky'e G41 d �_� city, kiat Site PM ` Z� 7 Owner's Nam ~' � Address � 1 Phone 1P� Contractor Address License No. Phone TYPE OF WELL/PNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR C] OTHER ❑ �y DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottoi m ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public i 1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation • ___-.-Approx. Depth}. l I Eastern- Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR DDITION JIQ DESTRUCTION i 1 Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence J Commercial_ Other ` Number of living units: Number of bedrooms w Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line r 'Y LEACHING LINE No. & Length of lines Total length/size Aob FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number A SUMPS CI Distance to nearest: Well Foundation AY Property Line= DISPOSAL PONDS ❑ I + i I 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 ce in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Cal' The appl- nt must call f quired i i s. omplete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USEONLY Application Accepted by Date y Area Pit or Grout Inspection by Date Final Inspection by Date �-�.3 e i Additional Comments: . ` 4.1 P- EI ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma(t ca 823-7104 ❑ Tracy 835-6385 vu�c.s K u,wrn. Applicant=Return all-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 yo /e-,clti a_a �r 3 .SLI OY �c�-• INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH 3-24+ EH 14-26IREV.iin51 'f V �® l ��