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` APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED f lComplete 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 t j Local Health District. a Job Address A7100 14 04&& Ja City Li of Size Q fPM s Owner's Name V ��4t� ��D e Address ph R � �r�� maw y� �o_ Contractor !1� Addressle&+A �J Lief one TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT © DE TRUCTION ❑ /f fvj' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLID ROP. 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 wen.casing 0 Domestic/Private L7 Gravel Pack ❑Tracy Type of Casing Specifications �I 171 Public 11 Other 11 Delta Depth of Grout Seal Type of Grout`f 1 I Irrigation --Approx. Depth I 1 Eastern Surface Seal installed by _ f Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material;top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATON I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet_( Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms- f� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Na. Compartments PKG, TREATMENT PLT.Q Method of Disposal { Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS II Depth Sire Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prel1ired this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 taws 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 applicantE applicantcall for 811 required inspections. Complete drawing an reverse side. Signed Title: ►�Df'fA7�/ACJ FOR DEPARTMENT USE ONLY 1_ Application Accepted by Date T t t Area i. Pit or Grout Inspection by Date Final Inspection by Date `I ` Additional Comments: 0 5tk 466.6781 ❑ Lodi 369-3621 p Manteca 823-7104 ❑ Tracy $35-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2UW_Stk., CA 95201 i I� FEE AMOUNT DUE AMOUNT REMITTEE] RECEIVED BY INFO ) PATE PERMITNO. •EH 20(REV-I/R 51 W2E EM 14 ✓ �.7 �i�%%J .