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APPLICATION FOR PERMIT _ f SAN JOAQUIN LOCAL HEALTH DISTRICT �s 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)466<8189 PERMIT EXPIRES TYEAR FROM DATE ISSUED Q (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. Job Address 5, City l� tot Size /SX r 6e PM Owner's Name `: l! { fe e-r Address "'�� 5 C 1 5! Phone : —714 Contractor *:e� 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 FLO. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS «1. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public FI Other Cl Delta Depth of Grout Seal Type of Grout _.. I i Irrigation _Approx.�0epth 1.1 Eastern- -. Surface Seal Installed by _ v Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth I Filler Material (Below 50'1 l TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTIONX(No septic system permitted if public sewer is \' available within 200 feet.) +tvY Installation will serve: Residence Commercial_ Other re Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg` Capacity No. Compartments v Disposal PKG. TREATMENT PLT. ❑ Method of Dis I� � p Distance to nearest: Well Foundation Property Line {� LEACHING LINE ❑ No. & Len th of lines Total length/size y \ FILTER BEd ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line I` DISPOSAL PONDS ❑ 1 I hereby certify that t 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 District. Home owner or licen$ed 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 taws 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 must call for allrequired inspections. Complete drawing on reverse side. Signed X-- �yz Title: © Date: FOR DEPARTMENT USE ONLY f! Application Accepted by Date Areal L ,__T Pit or Grout Inspection by Date Final Inspection by Date �1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Traly 835-6385 / (� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �I Q/ FEE AMOUNT DUE ' AMOUNT REMITTED CK RECEIVED BY GATE PERMIT'NO, INFO CASH ♦ EH1 -21rREV.tiHSY ��, �� Y /3 �� ' /✓I�� EH 114-29