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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 0 1601 E. HAZE'TON AVE., STOCKTON, CA '. Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED s (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 `//7 City Lot Size�A /00 f PM _ Owner's Name a Address � ) Phone Contractor 1R► Address I ',/ d li �� License No. 30aZ� Phone —353 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 k � FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia."of Well Excavation Dia. of Well Casing [I Domestic/Private L1 Gravel Pack L1 Tracy Type of Casing Specifications z ('1 Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout — q 11 Irrigation Approx. Depth i1 Eastern Surface Seal Installed by Repair Work Done- ❑ Type of Pump H.P, - State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material 1Below, 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I-I—REPAIR-1•ADDI710N!- —DEST=RUGTION i i-(No-septic system permitted if public sewer is available within 200 feet.) Installation will serve: -Residence Commercial, Other I Number of living units: J— Number edrooms__arses- r I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 'CY Type/Mfg 4e- �l- Capacity 1600 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WellS4Q rr Foundation `O Property Line Q r f JEACHING LINE LVr'No. & Length of lines �MTotal length/size 40 FILTER BED ❑ Distance to nearest: Well -74911, -,4'undation ®r Property Line. 0 SEEPAGE PITS iLl�Depth 2 c� ( t'•:t°.s Size. tr—% Number J1. SUMPS Ll Distance to nearest: Well 100 Foundation #Q1 _ Property Line DISPOSAL-PONDS C7 ¢ �- 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 Locil Health District.: r 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 I certifies the following: "I certify that in the performan_ce_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 or V required inspections. Compl€ete drawing on reverse side. Signed ' rr r . Title: eA tate: FOR DEPARTMENT USE: ONLY rte, �.f Application Accepted by ' Date w Area Pit or Grout Inspection by Date _Final Inspection by Date Additional Comments: �N ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 �M ❑ Tracy 835-6385 ' Applicant- Return all copies to: Environmental..Health_Permit/Services.1601k E. Hazelton Ave.,..P..O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT'NO. INFO CASH¢�w + EHp 13.241REV,i/n51 EH t4-28 IM