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APPLICATION FOR PERMIT l v D _411rl SAN JOAQUIN LOCAL HEALTH DISTRICT S cf 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) T� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work'fi _Tbr`s appkcation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Ftegu)ations of the San Joaquin Local Health District. ' // /J Job Address 5�� /City/rj/�e//�Q/J��e�__ PM Owner's Name Q-f ® ZA �'i` T fir/ PhoneContractor ddress / �' License No. (D�J Pho4� TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT C] DESTRUCTION E3 (^ PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER EIV 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ ther ❑ Delta Depth of Grout Seal Type of Grout I Irrigation �Approx. De I astern Sµrlep@ Seal Installed by - Repair Work Done Type of Pump H.P. I/ U State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public lis available within 200 feet.l 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 CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 li a '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 on in such man er as to b ome subje workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the (lowing: "'I certif hat in th rma a the work for.which this permit is issued, 1 shall employ persons subject to workman's compensa tion laws California.' The appli nt m all ra 1 ate drawing o 6v side.. ��(y Signed X Title: FFOR /DEPARTMENT USE ONLY Application Accepted byDate r�e,, Areal _—gyp Pit or Grout Inspection by Date Final Inspection by `°' "'9 Date=�0 61 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO EH i47e ✓✓