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i. APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �y� Job Address City,///1V,—Z�_&Lot Size PM Owner's Name 1 Address �1 �� ] l� Phone - �`1� Contractor dress I - License No. �Qr�� Phone TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XL SYSTEM REPAIR L3 OTHER LJ1i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1W(+ DISPOSAL FLD'.� PROP. LINE FOUNDATION AGRICULTURE WELL rA—`Vv+h�r�C—OTHER WELL PITS/SUMPS /CJO/Ce III INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cfl� 'Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f] Other f-1 Delta Depth of Grout Seal Type of Grout I i .Irrigation 15S-.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump 5 H,P. _'y State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION L'1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: i Number of bedrooms_ t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �T SEEPAGE PITS i I Depth Size - Number SUMPS D Distance to nearest: Well f` Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws, and ! rules and regulations of the San Joaquin Local Health District. ' � Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of employ any person in such manner as to become subject to workmanthe work for which this permit is issued, I shall not '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." The applicant u call for all required inspections.'Complete drawin on reverse'side. 1 Signed � i e: ( i Date: 4 FORA ARTMENT USE ONLY Application Accepted by - ` - Date Area Pit 6 GG,. nspection by ate inal Inspection by pato/ Additional Comments:A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT1UUE---Wat NT'REMITTEb K -- INFO H �� F" -,EIVED,BY DATE PERMIT'NO. r.EH1324 IREV.4/H 51 /1 i a c ��'7� EH 142e V l