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if APPLICATION FOR PERMIT 71 �p4q SAN JOAQUIN LOCAL HEALTH DISTRICT =�- 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I� PERMIT EXPIRES 1 YEAR FROM DATE (SSU€ 05/ (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the 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 a lations of th n Joaquin Local Health District. I' Job Address Cit Lot Size PM cie$,C Owner's Name Address Phone I 'C ContractorAddress License No. Phon RUN Inn_ +TYPE OF WELL/PUMP: Ji, .- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL F♦_D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing ❑ Domesticl Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications 1 Fl Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _. N I 1 Irrigation —.'Approx. Depth 1. 1 Eastern Surface Seal Installed by _ f Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'i Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION T.1 REPAIR/ADDITION l 1 DESTRUCTION Wo septic system permitted if public sewer is li available within 200 feet.] I � {1 Installation will serve: Residence_ Commercial_: Other Number of living units: _ IN Number of bedrooms ` 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK; 1 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ II..._ v� + .* Method of Disposal r Di an,,to nearest: Well Foundation Property Line l•� LEACHING LINE , ❑ No. & Length of lines Total length/size FILTER BEDx "o—Distance to nearest: Well Foundation Property Line e II - SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONOS 11 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 San4Joaquin 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 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 California." iii The applicant mu t call for all r quire i spections Complete drawing on reverse side. n Signed x�� Tide: Dt1vl�— Date: F FOR DEPARTMENT USE ONLY Application Accepted by Date Area ' I . Pit or Grout Inspection b �� Date Final Inspection,by Date r l Additional Comments: r II _0-Stk.-.466-6781_-E].❑.Lodi.4369-3621—0.Manteca-823-7104-__EJ.Tracy-835-6385. -- Applicant- Return aIt copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EH13-24(REV.1195) ��•Ut] C� � G a� �` C r1 �� EH 14-26 f