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4 APPLICATION FOR PERMIT d I SAN JOAQUIN LOCAL HEALTH DISTRICT (� 2 1601 E. HAZELTON AVE., STOCKTON, CA Al1CT 197 r Telephone (209) 466-6761 NTAL HFALTI� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NFIERMIT/SERVICES, (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 17 I mA City Lot Size Y� PM Owner's Name r0 j� EO//Jn T- Address 0ANIX eol "^/l '` �1 4MAD&One Contractor Address 7yg7 E 4'� Q"W nse No. -Phone 33 _I -70 TYPE OF WELL/PUNEW WELL WELL REPLACEMENT ElDESTRUCTION ❑ • PUMP INSTALLATIIOONN,❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD.-/4!:2_ PROP. LINE V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (- _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing D Type of Casing— 4- < Specifications / -I ' Domestic/Private ❑ Gravel Pack ❑ Tracy YP 9 �/ f ❑ Public ❑ Other n Delta Depth of Grout Seal O b Type of Grout--q _— r I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I availabo eptic system m permitted it public sewer is 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 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 ❑ Distance to nearest: Well Foundation - Property Line 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." Contractors 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 st all for all requi d inspe mplete drawing on reverse side. / 7 Signed Xf Date: 4F/z FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by A�LDate Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. INFO • FX It-W IREV1,X51 7// h/ R7 rW