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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 "/ J /l.! City Lot Size 2tJPM Owner's Name .7, c Address GY�L �;� Phone Cz ContractorAddress� 'tet License No. t_ 'Phone"" _� 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 -.r-w• ,,; PUMP INSTALLATION ❑ N` "SY-STEM.REPAIR ❑ t OTHER ❑_ f DISTANCE TO NEAREST: SEPTIC_,TANK, SEWER- INES - - DISPOSAL FLD. 4 ? PROP. LINE a ., FOUNDATION- ?_'_-.AGRICU UREV5L OTHER WELL PITS/SUMPS '. INTENDED USEV `'�'}TYPE OF WELL F PROBLEM AREA IVST.RUCTION SPECIFICATIOfVS+{ *"` f ❑ Industria! "❑ Open Bottom I]-Manteca > - Dia_of,Well Excavation " { Dia. of Well Casing r r ❑ Domestic/Private ❑ Gravel Pack •f❑ Tracy I ;1 Type of Casing f I Specifications 1-1 Public Cl Other f-] Delta epth of`Zarout Seal Type of Grout 1 1 Irrigation --Approx. Depth l I Eas rn urface Seal lnstalied by Repair Work Done ❑ Type of Pump H.P. s State Work`'Done r i Well Destruction ❑ Well Diameter Sealing Material [top 5.,-0'1 i Depth Filler Material !Below 501 r a TYPE OF SEPTIC WORK: NEW INSTALL l REPAIR/ADDITION {.I DESTRUCTION I I !No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms oS1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments 1 PKG. TREATMENT PLT. ❑ '' f 4 Method of D" posal ._ 1 0. r� Distance.tito nearest: W:rell��/_.._ Foundation� Property.Line JW Af LEACHING LINE 0 No. & Length of lines Tota! length/size Irl U If FILTER BED ❑ Distance to nearest: Well/(; Foundation_y(3 Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 11 .Distance to.nearest: Well Foundation_-. Property Line DISPOSAL PONDS ❑ 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. r M Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issded, 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 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." r The applicanpTust call f it requir inspections. C ete drawing o reverse ide. Signed X ., Title: ��y "�.A Date: FOR DEPARTMENT USE ONLY Application Accepted by t� Date rCa — 7Area ' Pit or Grout Inspection by Date c Final Inspection by = Date 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE AMOU R1 MITTED CASH I RECEIVED BY /DATE t PERMIT-ND. +.EH -21[Fit V.f i K 51 i4 EH 11-26