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t ' 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address `� ' ICIDCity Lot Size PM _ �/ Owner's Name 1,L S Address (� (�� Z Phone x Contractor Address '(� T _f3 License No. Phone TYPE OF WELLlPUMP: _NEW WELL ❑ R�� WELL REPLACEMENT ❑ DESTRUCTION ❑ f� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ L DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 'L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ IN ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indu rial ❑ Open Bottom E1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Dom stic/Private El Gravel Pack 171 Tracy Type of Casing Specifications fi Public n Other 1771 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I i Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material atop 50'1 4 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION (.] DESTRUCTION No Septic system permitted it public sewer is available within 200 feet.} Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 77 TREATMENT PLT. ❑ Method of Disposal jDistance to nearest: Well Foundation_ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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 lawsand 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certi , n : "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- laws of California. The a 'c It m r re inspections complete drawing on reverse side. Signed X Title: Date: - ,EOR DEPARTMENT USE ONLY 67 Application Accepted by Date p ,"" � Pit or Grout Inspection by n Date Final Inspection by Datep Additional Comments: /® S ❑ Stk 466-6781 ❑ Lodi -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 REMETTEp INFO RECEIVED BY DATE PERMIT'NO. + EH114.26 3-24IAEY EH .rin5i � 0� fq/ S e- 3