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4,1 I APPLICATION FOR PERMIT ` i t SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZETON AVE., STOCKTON, CA j 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 aquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations oDS sSan.W Local Health District. City Lot Size �� PM Job Address �- �0 5 y 1. � � 1 i t .-� �► Phone Owner's Name _ "Address _- Phone, r 4 Contractor License No. ddress t DESTRUCTION ❑ : { TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ x DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA C ST UCTION SPECIFICATIONS t Dia. of Well Casing 1:1Industrial ❑Open Bottom El Manteca Di Well Excavation Specifications ID Domestic/Private ,.;0 Gravel Pack ❑ Tracy Ty of Casing p M PublicFi Other C1 Delta th of Grout Seal Type of Grout t I I Irrigation } `_.Approx. Depth 1 I Eastern Su ace Seal Installed by - Repair Work Done F. ElType of Pump H.P. 'State Work Done -.r x F f Well Destruction' fes❑ Welt Diameter 5 Ing Material )top 50°! . �' Depth filler Material l6elow 501 i. f. TYPE OF-SEPTIC WORK: NEW INSTALLATION I c REPAIR/ADDITION t 1 DESTRUCTION I } iNO septic 'system-permiRed if public sewer i5 . } available within 200 teet.l r Installation will serve:-Residence_ Commercial Other �. t G 'Number of living urflts: N6mbill bedrooms ' - .--___xWater table depth Character of soil to•a depth of 3 feet: SEPTIC TANK 4 El Type/Mfg % Capacity U No. Compartments t Method o is osal Ill TREATMENT PLT. O €—�/��,� �� y Property Line Distahce to nearest: -Well '! U_ti� Foundation P y 1 11101 k LEACHING LINE 17-1 No. & Length of lines - Total length/size ,�,i FILTER BED ❑ Distance to nearest: Well,ir� �Z Foundation Prope Linej• SEEPAGE PITS I i Depth Size Number SUMPS ❑ Oistance'to nearest: Well y`-'"-`_- Foundation CO -4 Property Line I 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 laws, and rules and regulations of the San Joaquin-'Local Health District. f ' ` 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 certifies the following: "I certify that in the performance of the work for which this permit is issued,["shall erf pjoy persons subject,to workman's compensa- tion laws of California." The applicant ust call for a required inspections�Complete drawing on reverse side. . '� -,. Date: _/� Signed X Title: r FOR DEPARTMENT USE ONLY Application Accepted bybate Area r, Pit or Grout Inspection by ' _ Date ' � Final Inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.`Hazelton Ave., P.D. Box 2009, Stk., CA 95201 � 4 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIt'NO. M a EH 13-24 Ill /H 51 _ f, Ell I . i R