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x-i APPLICATION FOR PERMIT 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 heteby 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 CountyArdinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address City/ '`/� Lot Size PM � /� , O Owner's Name •Andre% 9�3�� / E4r/E no/ "2� Contractor Sc- Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Open Bottom ❑ Manteca Dia-of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -_ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repan Work Done ❑ Type of Pump M.P. State Work Done_ Well Destruction ❑ Wail Diameter Sealing Material Itop 501 Depth Filler Material(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION 'No septi[system permitted if public sewer is avaHable within 200 feet.) UJ 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 Pli TREATMENT PLT. ❑ Method of Disposal / Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 D3trict. 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: "1 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 must for all requir spectio Complete drawing on reverse side. Signed X e: �" �'-r o�1. Data: / R D2%t USE ONLY Q Application Accepted by Data / o Area Pit or Grout Inspection by Date Final Inspection by Dz �1� Additional Comments: ��U Cl Stk 4666781 ❑ Lodi 3443621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2OD9, Stk., CA 95201 fEE AMOUNT DUE AMOUNT REMITTED RECEIVED BV GATE PERMI7-N0. �1 NFO `IJA H • EM 1l