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N ' APPLICATION FOR PERMIT ud SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Ins Telephone (209) 466-6781 SLP PERMIT EXPIRES T YEAR FROM DATE ISSUED NTA4. HEALTIA (Complete in Triplicate) ENF� 11T/SERI 101-5 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. I JobAddress _d �*—f_c'� ' City Lot Size PM Owner's Name r Address O c'3C-0, -- Phone Contract- Address 41'- I a e No, f7 Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION,( SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1.9�Domestic/Private Q Gravel Pack O Tracy Type of Casing Specifications M Public ❑Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done tY, Type of Pump H,P. State Work Donah Well Destruction ❑ Well Diameter Sealing Material (top 50'l Depth Filler Material lBotow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is �1 available within 200}eet.I Installation wilt serve: Residence Commercial— Other Number of living units: Number of bedrooms 4 `' I Character of soil to a depth of 3 feet; Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0 SEEPAGE PITS I I Depth Size Number j SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS' ❑ I hereby cenify 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 Di4trict. 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,I shall employ parsons subject to workman's compensa- tion laws of California." The applicant mu. it eft requiredrns ections. Complete drawing an re arse side. Signed Title: Date: Fp DEPARTMENT USE ONLY Application Accepted by _ 01 �� f _ — bate Area Pit or Grout Inspection by Date Final Inspection by OatB ^(j' Additional Comments: ❑ Stk 465781 ❑ Lodi 359-3621 Q Manteca 823-7104 ❑Tracy 8355-83$5 Applicant- Return all copies to. Environmental Health Permit/SeMmas 1601 E. Hazalton Ave., P,O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTER CK RECEIVED BY INFO CASH PATE PERMIT'No. EH 13-24 fREV. EN F626