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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT A1601 E. HAZE``T ON 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2 �-�/tY�dl�� City Lot Size L PM Owner's Name Y Address Phonel�� Contractor M0119—a-75' Address License N'0-4110[.02 q K Phone TYPE OF WELL/PUMP: NEW WELL'❑ WELL-REPLACEMENT ❑ .� DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E WELL OTHER WELL' � PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS j LJIndustrial EJOpen Bottom C1Manteca Dia. Well Excavation .Dia. of Well Casing El Domestic/Private C1 Gravel Pack LJ Tracy Type o ,asing Specifications•(' 1'1 Public ❑ Other f 1 Delta Depth of out Seal Type of Grout _ I 1 Irrigation _Approx. Depth l I Eastern Surface Sea nstalled by .Repair Work Done ❑ Type of Pump H.P. State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material Itop 50 F Depth Filler Material /Below 50) TYPE OF SEPTIC WORK: NEW INSTALLATION kf REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within-200 feet;) Installation will serve: Residence Commercial_ Other r s { Number of living units: Number of bedrooms haracter of soil to a depth of 3 feet: s Watertitable depth SEP TANK ❑ Type/Mfg Capacity- No. Compartments PKG. T TMENT PLT. ❑ t Method of Disposal ..— - �+ Distance to nearest: Well 4 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i i SEEPAGE PITS i I Depth Size��` X Number CrJ a I SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 DISPOSAL_PONDS h+ f 5cT CTL Fc 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 focal Health District. ; µ 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, l 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 work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicantmust st call for all required inspections. Complete drawing on reverse side. ( 1r-- Title: t^'Uate: Q p Signed X FOR DEPARTMENT USE ONLY Application Accepted b "4+"` - Date Area Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ` Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO E + EH 13.24(REV.I/x 5) "n 1 - i_ F EH 14-24 11