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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 3 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 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 / / 76 Al,�^ 1. � r City AK Lot Size PM Owner's Name • it Address Phone A Contractor /T, �::Address 67, t-r�4.w License No /l�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR (] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LIME 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 Ci Ddmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public n Other F1 Delta Depth of Grout Seal Type of Grout o 1.1 Irrigation Approx. Dep�lT) I Eastern Su c e I Installed by Repair Work Done on * Typ2 of Pump H.P. State Work ne Well Destruction ❑ Well Diameter . Sealing Material (tAlp 5011 Depth Filler Material (Below 501 IRV" r TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if publ' gew �.2 T available within 200 feet.) l/!f Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth 1, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \ PKG. TREATMENT PLT. El Method of Disposal \ I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Eine li SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation- Property Line DISPOSAL PONDS ❑ 1 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 not1. employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes hiring or sub-contracting signature`v certifies the following; "I certif in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif The applica ca f r I e re to c-ons. plate drawing o re slde� - Signed X _ Title: ,( 'J ` Date: f FOR DEPARTMENT USE ONLY.- Application Accepted by `� �1.�1L Date `7 Lam~`� Ara. __ __O6 Pit or Grout Inspection by Date Final Inspection by _( Date Additional Comments: { &Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ID Tracy 835-6385 licant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j FEE AMOUNT DUE AMOUNT REMITTED CK Z RECEIVED By DATE PERMIT NO. INFO - . EH73-74(REV.I i N 5) �� EH 74-26 '( /�