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APPLICATION FOR PERMIT 'TAN JOAQUIN LOCAL HEALTH DISTRIICt 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 e -L 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.TMs 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 9; '; /—y 1/f. ? 1 (- C7 P City J<ry.(a_.--tot Size PM Owner's Nam ` _ Address S /A�...�� Phone Contractor J � Ec-c.. �7��.C.Address ,�co`� License No.32/A-6/16— Phone Z. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR V- OTHER ❑ 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 00-p en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_. I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done lQ Type of Pump -_141/ H.P. r10 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) 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." 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 aip m call for all req ' inspe dons. Co plate drawing on revBr4e side. Signed Title: �`/lam S Date: jf///'�r/ FOR DEPARTMENT USE ONLY _ Application Accepted by v. i� Date 's ' Area Pit or Grout Inspection by Date Final Inspection by Dater Additional Comments: ❑ Stk 4664781 ❑ 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 NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. �.EH 1}2/IREV.1iXe1 EH 1 -m 61