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N� APPLICATION FOR PERMIT Iv./ .� 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 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 11 Job Address e r City 1��ot Size PM Jvrt [ `' (503--2/1-7 Owner's Name V Address l l� 6L W4a �� Phone 95 .1.5 Contractor sie T 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 1i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout— - I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - 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 I 1 REPAIR/ADDITION I I DESTRUCTION A INo septic system permitted if public sewer is available within 200 feet.) ry Installation will serve: Residence_T 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 _ - -, I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .. I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/sue FILTER BED ❑ Distance to nearest: Well Foundation Property Lire SEEPAGE PITS I I Depth Sue Number _ SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." 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, I shall employ persons subject to workman's compens i- tion laws of California." The applicant e� call for all required ins actions. Complete drawing on reverse side. %Signed X Title: Date: V_ew e4 � � q 9 FOR DEPARTMENT USE ONLY (� p.G Application Accepted by /Dat/e c7 _,U�Gl! AreaLf Co, 1,e. Pit or Grout Inspection by Date Final Inspec on y Date Aa Sfaf t . ` Additional Comments: -�^� ❑ Stk 466-6761 ❑ Lodi 3693621 ❑ Manteca 623-7104 ❑ Tracy 836-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (UUl FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO /(7�rL�/ r 2 . EH 1124(REV.1/n 5) �� ` 141 `� 1 ^k/l EH 14 M J �l 1