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v APPLICATION FOR PERMIT pp SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 uu�7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED stp (Complete in Triplicate) ENVIROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct end/or install the v#�( �tPegCFi}��idi s application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an egu atrons o e San Joaquin Local Health District. `f Job Address 1-�6 8 City �-�J� Lott Site - PM Owner's NameAddress -'G/( Phone r �y� Contractor d Address License No,,M5,74 // Phone TYPE OF WELL/PUMP: NEWWELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR jf7Y— OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fi 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 J;-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx...Deplh. 1 11 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump N.P. Q — State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth 'I Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer�s available within 200 feet.) Installation will serve: Residence Commercial_ Other \1 1 \ Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet:I Water table depth - SEPTIC TANK ❑ Tyi Capacity No. Compartments PKG. TREATMENT PLT. ❑ II Method of Disposal V Distance to nearest: Well Foundation Property.Line . I LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth I Size Number SUMPS ❑ Distance to nearest: - Well Foundation Property Lina DISPOSAL-PONDSu ❑ c ++.-- 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 Heal 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 subcontracting signature certifies the following:;'1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant musiogall for all regi r nspections. mplete drawing on reverse side. i 1 Signed rias: Data: g 30 1 . .1 i ^ FO EPARTMENT USE ONLY Application Accepted by _ Z - Date Area Pit or Grout Inspection by •� Date Final Inspection by 2` Date Additional Comments: I y ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 8 FEE AMOUNT DUE. AMOUNT REMftTED CASH RECEIVED BY DATE PERMIT'NO.' INFO 1101 1344(REV.tins � EH 11-m �J