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r P;7 e.J __1\ APPLICATION FOR PERMIT I r� SAN JOAQUIN LOCAL HEALTH DISTRICT W 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone 5209) 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. Job Address (O © L� U� Cit Lot Size PM Owner's Names-J R Address Phone Contractor VALTk)RLL C]1J$ Address V+ License No. 3cx]� phone 9E-�S 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -4 I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION.[,]�REPAIR/ADDITION I l DESTRUCTION N1JplQ s%TM system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence�C ommercial_ Other ' Number of living units: I Number of bedrooms ;�n_ , 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 f t 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 SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line 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 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 Qrtifies the folio in "I certify that in the performance of the work for which this permit is issued,I shatl employ persons subject m workman's compensa tio ws of California.' The apph t ust call r all quir ins tie Complete drawingZ;�� Sig Title: Date: FOR DEPARTMENT USE ONLY �] Application Accepted by Date 5—,, Area Pit or Grout Inspection r DateFinal Ins cti n py A Date Additional Comments: F►^+ J U 54 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Avg., P.O. Box Stk., CA 9 1 IFEE �f/(!AMOUNT DUE AMOUNT REMITTED C Kikl SH RECEIVED BY DA PERMIT*NO. ` + EH 13-24)REV.i/r:51 W& - SS,f7 EH T4-21i - `