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APPLICATION FOR PERMIT �AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. ((�//�� ,(/n� 10 Job Address WiL-12e/�f/�/ , Ciev' Lot Siza9� � PM Owner's Nan , r r Address /A1 / Phone Contrac icense No. ZYZ P hone 'S�" aym, 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 0 t. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C` M 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 Itop 50') ` - Depth - Material (Below 501. TYPE OF SEPTIC WORK: NEW INSTALLATION EP ADDITIO DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res' ence_ Commercial Other / _ Number of living units: Number r m� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ 'Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINENo. 8 Length.of lines T);`tal length/size FILTER BED ❑ Distance to nearest: Well 6W Foundation eio _ Property Line - i004 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." 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 dornia" The applicant u call for r uiro inspections. Complete drawing on roversss��}s Signed Title: e Date: C!/ FOR DEPARTMENT USE ONLY (� V Application Accepted by �w�\�� Date 'S�—��'-'�1 Area - I Pit or Grout Inspection by Date Final Inspection by`-,1�'�\h-��. Date _-A dd it..al Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Se601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT D AMOUNT REMITTED I CK 0 CASH RECEIVED BY DATE PERMfT NO. EH/344 1REV.11.5) I I�rJ '1 �- t'�L I 9 I -o,166 EH IL]a