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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I! 1601 E. HAZE T ON AVE., STOCKTON, CA "o`^ b� Telephone (209) 466-6781 (1r•p .�o +,t�. PERMIT EXPIRES 'I YEAR FRO MPDATE 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 Addtess ' city. Lot Size PM. „I. I Owner's NameL -, l Address _ •` ` ' II Phone Contractor F[.4yD 6�• . Address rd .S W. L/t,4.e ^/ TYPE OF WELL/PUMP: ii License Na. 71_ Phone 7 ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i II PUMP INSTALLATION ❑ SYSTEM REPAIR C-1OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION DISPOSAL FLD.# PROP. LINE { AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manteca . Dia. of Well Excavation. F ❑ Domestic/Private ElGravel Pack ❑;Tracy Dia. of Well Casing 4 Type of Casing + C1 Public'' ❑ Other Specifications a ❑ Delta Depth of Grout Seal '. ❑ Irrigation �� Type of Grout _._�Approx. Depth.f; ❑ Eastern s'! Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump €a H.P.Well Destruction LJ Weil Diameter State Work Done Sealing Material (top 50') [� Depth • Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ rFEPAIR/ADDITION ❑ DES111 TRUCTION iNo septic system permitted if public sewer is y"" R 'available within m feett Installation will serve: Residence -V Commercial_ Other Number,of living-units: _ 4., Number of bedrooms 4 r`r Character of soil to a depth of 3 feet: R SEPTIC TANK T e/Mf ►Nater table depth Type/Mfg PKG. TREATMENT PLT. ❑ I -r • � .Capacity No}Compartments ( Method of Disposal Distance to nearest Well Foundation ` Property Line LEACHING LINE ❑ No. & Length of lines r FILTER BED Total length/size] ❑ Distance to nearest: Well Foundation II Property Line f j I SEEPAGE PITS ❑ Depth Size SUMPS Number 3 ❑ Distance to nearest: , Well Foundation DISPOSAL PONDS ❑ �� j Property Line + ` 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. Hams owner or licensed agent'sisignature certifies the following: � � .x. employ an g: "I certify-that in the performance of the work for which this permit is issued, i shall not p Y y person in such manner as to become subject to workman's compensation laws of California."Contiactor's hiring or sub-contracting signature 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." f r The applicant must call or all required in spections. omplete drawing on reverse side. i Signed :III. y Title:} r Date: —F f FOR DEPARTMENT USE ONLY Application Accepted by IYt� . ".."' afs"'-". ._�.`� Area Pit or Grout Inspection O s Data Final Inspection-by z II . + �..► Ji j—'J f Date Additional Comments: ;. -►. ElStk. 466-6781 ❑ Lodi X369-3621 ❑ Mante 823-7104 ' ❑ Tracy 835'6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNTk DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE j11ER1M11�TN]O+ EH 13-24 1RE'V.i i e s)EH 74-28 . II