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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ii Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. 1662 for well/pump and the Rules and Regulations of the$an Joacluin Local Health District. li Job Address �:9� � Ld/.d�AM Z`/'. 9, _..,_,_,-- City Lot Size Ia?xana PM Owner's Name P leiai'.I d. Ym — Addressd � irt-G6t ter` Phone ii Contractor Address A License No._r'W Phone..3i — S TYPE OF WELL/PUMP: !; NEW WELL L) WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE x FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v 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 F1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout_., _. I I Irrigation. Al .Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50') \ i Depth FillerMaterial (Below 50')TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No se is system permitted if puCOse r C� available within 200 feet.) Y. Installation will serve: Residence_ Commercial_ Other Number of living units Number of bedrooms 4 r Character of soil to a depth'!of 3 feet: Water table depth : j SEPTIC TANK ❑hype/Mfg - —Capacity _ - _ _ �No-Gempartments-,. ' ( PKG. TREATMENT PLT. ❑ it z• y Method of Disposal _ i Distance to nearest: Well Foundation ' * Property Line { '{ r ,s t LEACHING LINE ❑ No. & Length of lines Total length/size . F FILTER BED ❑ Distance to nearest: Well Foundation Property Line t ®®® {{ SEEPAGE PITS t l 1 Depth Size Number �R\ SUMPS" —` f ❑ 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 f employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Y 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." i The applicant must call for required inspections. Complete drawing on reverse side. I Signed X Title: Date: t II FOR DEPARTMENT KSE ONLY Application Accepted by Date ` lJ Area `f Pit or Grout Inspection by Date Final Inspection by Date L� r , Additional Comments: �I / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 L I INFO FEE AMOUNT DUE AMOUNT REMITTED BASH RECEIVED BY DATE jPERMIT'NO.+ EH4281REV.oix51 /�— �f" �(� ® Y