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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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address or 1kY City w� Lot Size PM Owner's Name 1 � [.rA!�Address ©J 0 /" s ,SSS' Phone E Contractor _ U_i, ;S _ Address_ CJ/ License Nd._ �.._ ��«.3�Ph0 � f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE 4 { FOUNDATION AGRICULTURE WELL # - OTHER WELL PITS/SUMPS k INTENDED USECONSTRUCTION SPECIFICATIONS TYPE OF WELL PR08LEM AREA'• ❑ Industrial11 ❑ Open Bottom ❑ Manteca &qi of Well Excavation Q Domestic/Private Q Gravel Pack ❑ Tracy T` Dia" of Well Casing i Q Public ❑ Other Type of Casing Specifications I \ 1,/ ❑ Delta Depth of Grout Sea! Type of Grout 6 " � Lid Irrigation —Approk-Depth ❑ Eastern a Surface Seal Installed by s '� Repair Work Done ❑ Type Of'Pumpf H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR_/ADDITION DESTRUCTION ❑ {No septic system .-�.._ �.. permitted if public sewer is Installation will serve: ResidencN�uber R available within 200 feet.) t Commercial_ jother Number df living units: of bedrooms Character•of soil to a depth of 3 feet: -, -rte ,..4 _ .� r ;+ SEPTIC TA.fVK ' t Water table depth t ;� Type/Mfg c f ,3 P Capacity_ . No. Compartments PKG. TREATMEIVT:.PLT: ❑ r 11 � Method of Disposal �. Distance to neat: Well Foundation r proLineI 3a ; __ '[EACHING'LINE t 1V0. & Len th of lines Total" ngth%size` I fL7ER BED -� ❑ Distance to�nearest: Well ' �° a .� >E } f� Foundation' property Line SEEPAGE PITS Depth Size ` /�=. SUMPS Number '"- 'C ~ ❑ Distance to nearest: Well ^" ! /- r f �`� - r Foundation __ Prope DISPOSAL PONDS ❑ ,<,ws rty Line lC5 )+hereby certify ihai I have prepared this application and that the work will be done in accordance witfi San Joaquin county ordinances, state laws, and rules and regulations of the Saar Joaquin Local-Health.District. } Home owner or'licensed agent's signature,cerrifies iFi+3rfol`win ,, # employ an lA g: '1 certify that in the performance of the work;for�rhich this permit is'-issued, I shall not p Y Viperson in such manner as to become subjet to`workman's compensation laws of Gafifornia." ontractoF's hiring or sub contracting signature certifies the�following: "I certifyrthat in the performance'of the work for which this permit is issued,I shat In employ persons subject to workman's compensa- tign laws of California." � ust call for all r ire_ nspectlons. Complete drawing on reverse side. Signed itle:-- _�- Date: t> e) CFOR DEPARTMENT USE Application Accepted by � '� � �• a � f , - _ _ Date Area 1 Pit r Grout Inspection by Oate tFinal Inspection by Dat es Additional Comments: \ �T XStk 466-6781 ❑ Lodi 369-3621 ❑ Meca 823-7104 ❑ Tracy mental plicant- Return ail copies to: EnvironHaalth Permit Services 1601 E. Hazelton Ave,, P.O, Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO (� CASH RECEIVED 8Y DATE PERMIT'NO. + EH 13-24 MEV.' /as7 EH 14-29 J