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I APPLICATION FOR PERMIT 4 r. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 descr8med-This application is made in compliianbe with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Q"��J�j f� 'I Job Address City - Lot Size PMLe . Owner's Name d't-'G Address f / a Contractor t l AddressLicense No.2_ki&_—Phone Z� r� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTAL TION ❑ SYSTEM REPAIR C3 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 SPECIFICA 1 p C� ❑ industrial ❑Open Bottom ❑Manteca Dia.of Well Excava n Dia.of Well Casing! omastic/Private {Gravel Packrracy Type of CasingSpecifications IPS l ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout * Irrigation —_Approx. Depth ❑ Easter Surface Seal Installed by e Repair Work Done L) Type of Pump H.P. State Work Done 1 Welt Destruction ❑ Well Diameter Sealing Material(top W) h Depth Filier Material(Below EO') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line j LEACHING LINE O No. &Length of lines Total length/size r FILTER BED 11 Distance to nearest: Well Foundation Property Una SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and rules end 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 cub-contracting signature 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.,, Theapplican u call r all q 'red inspections. Complete drawing on ree side. Signed Title: be _ Date: F PENT MSE ONLY G Application Accepted by Q� Date ( 4.V Area Ph orro Inspection b 9W, Date Finial Inspection by Date Additional Comments: —_--_ �� :K,2l 'of --- ❑ Stk 466-Ml ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑Tracy 8354= Applicant-Return all coples to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 136201 IF 0 AMOUNT DUE AMOUNT REMITTED CCK RECENED 13Y DATE PERMIT'NO. a EH 13-24IREV.1/aisi g � EH 14-211 /