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f 1 ■ ` k ., APPLICATION FOR PERMIT f j SAN JOAQUIN LOCAL HEALTH DISTRICT ,I 1601 E. HAZEL i ON 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. Mav q!9 Job Address ciit`y Lot Size PM Owner's Name ball '� � �� --.o Address cJ 14 _- Phone 2 Contractor Address License No.��/�Phone_ TYPE OF WELLIPUMP: NE ELL ❑ WELL REPLACEMENT-Q_ DESTRUCTION 0 rf�y� Gn we PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLO. PROP, LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack d Tracy Type of Casing do,IV, Specifications $c,(/4! Q F] Public n Other M&V, J, FI Delta Depth of Grout Seal Type of Grout . I I irrigation -_-Approx. Depth I 1 Eastern Surface Seal Installed by —4 h 3 _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION I I DESTRUCTION I I INo 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 i LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to_nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size .Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l 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 thaf 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: "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 must or all r fired inspe ons. Complete drawing on reverse side. c Signed X Titia: _ --- Date: Z2Q FOR DEPARTMENT USE ONLY �( Application Accepted by Date 4�;, U Area Pit or Grout Inspection by r_ ) p Date Final Inspection by Date 45 Additional Comments: ❑ Stk 466-5781 Cl Lodi 369-3621 ❑ Manteca 823-71046 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 113.24(REV.s/H5) � 1 1426