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n I APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT • 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. /�� Job Address 7 J Y 2n� Cir- Lot Size PM Owner's Name Phone16 - Contractor ddress d, No. �3G Phone TYPE OF WEL /PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ Industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing Specifications ` * Public ❑ Other ❑ Delta 1 Depth of Grout Seal Type of Grout—— J I I Irrigation _Approx. Depth IJ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done_ Well Destruction ❑ Well Diameter •Sealing Material hop 501 . Depth Filler Material(Belo 9 TYPE OF SEPTIC WORK: INEW INSTALLATION (I REPAIR/ADDITION Or DESTRUCTION I 1 ;No septic system permitted if public sower is • ( available within 200 feet.) t „x Installation will serve: Residence_ Commercial Zother a Number of living units: _ Number of bedrooms Character of snit to a depth of 3 feet: Water table depth SEPTIC TANK ❑I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑' Method of Disposal i I Distance to nearest: Well t Foundation Property Line j1 LEACHING LINE ❑f No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel undaltorr Property Line I SEEPAGE PI 1 I, Depth Size Number SUMPS 0 Distance to nearest: Well Foundation��._ Foundation Property Line DISPOSAL PONDS ❑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: '9 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."Contractoes hiring or subcontracting 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." The applicant st for n requi spections. Comp drawing on reverse e. - Signed X— 'T /yN+� �$_ Title: Date: R DEPARTMENT USE ONLY Application Accepted by a0L r�-J�9 meG Date Area Pit or Grout Inspection byt Date Final Inspection by Date Additional Comments: • ❑ Sal, 466-6781 ❑ Lodi 3633621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 FEE OUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFOJA //rr, CASM (� �jC ..EH 1124 IeEV.1r x 5; 70,02l./ �_�� ( (� -ID —4J) EH 14211