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%NO APPLICATION FOR PERMIT %./f 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 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 /3,2ga A), "1zY�,//A .t. Cit Lot Size, 0-4/ C� PM p Owners Name tMy Address r Phone Contract ' Address i), q 7 X F License No 2 Z L(e Phan `J /4rS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Isis PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Isis, 1.1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Uy Depth r Material (Bel9w 501 TYPE OF SEPTIC WORK: NEW INSTALJATION 17 kEPAIR ADDITIONX, DESTRUCTION I I INo septic system permitted if public sewer is .l Y/ available within 200 feet.) a. Installation will serve: Residence_ Commercial_ Other Number of living units: L Number of coma v /� 7 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 Linei FI Us LEACHING LINE Cl No. & Length of lines Total length/size „ FILTER BED O Distance to nearest: Well Foundation Property Line L Lr 7 SEEPAGE PITS Depth Size 13& Plumber r ,a SUMPS ❑ Distance to nearest: WeII��f Foundation_Zf) Property Line t DISPOSAL PONDS ❑ " ... I hereby certify that 1 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 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 persons subject to workman's compensa- tion laws of California." The applicant t call fo eq ed inspections. Complete drawing on ravers� c�r 1 Signed K Title: _ Yt Date: FOR DEPARTMENT USE ONLY flLApplication Accepted by J Date Area � / p Pi r Grout Inspection by� ate� � Final Inspection by_� Date r'-"--/�—/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. est . EH 1324 1REv.11.51 / _ 7� EH 142e �(.,