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0 j k t APPLICATION FOR PERMIT 't s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA i -6781 Telephone (209) 466 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) £. Application is heieby 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. Job Address �n CitYXLot Size PM -- �f Owner's Name �� bdress R d �1 r 11/,n ho c�%f-T'�'l�! Contracto�E� Ems_—Addresses �� r LlcenseNa. Pone TYPE OF LL/PUMP: NEW WELL �" WELL REPLACEMENT ❑ DESTRUCTION ❑ . DISTANCE,TO NEAREST . INTENDED USE VUstrial Domestic/Private ["1 Public r . I I Irrigation Repair Work Done ❑ Well Destruction ❑ .:4 WORK PUMP INSTALLAlTI�O��Nk;Y SYSTEM REPAIR ❑ OTHER ❑ SEPTIC TANK Lstti.__. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — TY E OF WELL 4 PROBLEMAREA CONSTRUCTION SPECIFICATIONS l pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack ❑ Tracy Type of Casing 5i�l Specifrcations �t 11 Other ❑ Delta Depth of Grout Seal Type of Grout -13�GT 1 �QApprox.. Depth��II+ Eastern µmace Seal Installed by - Type of Pumpsif H.P. _ State Work Done Well Diameter Sealing. Material (top 501 — .Depth Filler Material (Below 501 NEW INSTALLATION I l REPAIR/ADDITION LI DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence , Commercial . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/IA119 PKG. TREATMENT PLT. ❑ Other' - Water table depth - Capacity No. Compartments Distance to nearest: Well Foundation LEACHING LINE Ll No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Method of Disposal Property.Line Total length /size, Property Line M 0 SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation _ _ Property Line • s. 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 DiMrict. 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 wort: for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must 9011 for all fequiry inspe tions. Complete drawing on rgrse sid Signed X. Title: —� Date: 4. FOR DEPARTMENT USE Ot'11 Application Accepted by - Dat 1 ' Area—� Pit or Grout Inspection by ��p,YL r� p tee Final Inspection by Additional Comments: ❑ Stt: 466=6781 Lodi 369-3621 ❑ Manteca 823- 104 ❑ T cy 6 Applicant - Return all copies to: Environmental Health Permit/Services 1E01 E. Hazelton Ave ♦ EH 13-24 (REV. I/ e E EH I+-28 t P.O. Box 2CW, St4:., CA 957'01 Date d FEE' AMOUNT DUE AMOUNT REIAITTEO ' 0 N REC YED BY DATE PERMIT'NO. INFO 0 5 - MD