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APPLICATION FOR PERMIT �� SA°N JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA l Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 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 r 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 Hl74fll' - City Lot Size PM Owner's Name I �� s� Address � �� Phone Contractor=-- /' 4 Address OWN boigwnl Wy License No 2��Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1, ! PUMP INSTALLATION ❑ t SYSTEM REPAIR ❑ OTHER ❑ a _ DISTANCE TO NEAREST: SEPTIC TANK .. ' SEWER LINES DISPOSAL FLD. e PROP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca f Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Trac f Tracy Type of Casing Specifications I'] Public ❑ Other F1 Delta Depth of Grout-Seal y Type of Grout _ I 1 Irrigation -• ---.. ----.- -_-.Approx.--Depth I I Eastern �._Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done_• Y 1 Well Destruction 12 Well Diameter Sealing Material (top 50') . ry Depth - Filler Material (Below 50') TYPE OF SFPTIC.WORK: NEW INSTALLATION I] REPAIR/ADDITIONX DESTRUCTION i I (No septic system permitted it public sewer is available within 200 fee't.I Installation will serve: Residence Commercial t Other 7AV y Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: A-h�JP� - ; _r ` _Water table depth 1 �s. r 1 SEPTIC TANK X, Type/Mfg . Capacity��` X=f 0. Compartments , PKG. TREATMENT PLT. ❑ f .Method of Disposal Distance to neorest:""N7ell� .,-..__ Foundation �j�5 .__-Property Line LEACHING LINE Q6.57_0 No. & Length of lines ` k' Total length/size` FILTER BED ❑ Distance.to nearest:: Well Foundation Property Line SEEPAGE PITS 11 Depth Size , Number SUMPS Y ❑ Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ 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 Di`sfrict. 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 N employ any person in such manner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature t 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 all req uir i pact ns. Complet drawing on reverse side. / �j 7 Signed Title: � Date: f_ FOR DEPARTMENT USE ONLY Application Accepted by Date d -!} A Area JAI t Pit or Grout Inspection by Date 1 Final Ins ection by Dater Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1 Q Manteca 3-7104 - ❑ Trac 835- 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. +.EH 13-21(REV.1/H5) J 10 (J r6 �,,..EH 11.29