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i APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT I 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 _ tnb� L� i City Lot Size PM j Owner's Name u tS Address �� '��-a y Phone 7` Q Contractor Sro✓ Address 0. k �✓ License No.�_Phone 0 TYPE OF WELL/PUMP: NEW WELL 1-1WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEREPAIR-13-` "`"OTHER ElM- �+ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES E DISPOSAL�:L'D.^ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 4' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13 Dia. of Well Casing j E] Domestic/Private EJ Gravel Pack Q Tracy Type ofkCasMg Specifications r ❑;Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout l El Irrigation ---Approx.,Depth }-,❑ Eastern Surface+Seal-Installed by - �--- S' Repair Work Done LlType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 ' c Depth Filler Material IBelow 50'1 s• - TYPE OF SEPTIC WORK: NEW INSTALLATION C]`i;REPAIR/ADDITION& DESTRUCTION 0`(No septic system permitted if public sewer,is n '`available within 200 feet.) IXJ Installation will serve: Residence_, Commercial 'Other ` Number of living units: A— Number of bedrooms 1 Character of soil to a depth of 3 feet: P"•.rte I '' Water table depth i SEPTIC TANK ❑ Type/Mfg � 4.Capacity ' r No Compartments t' PKG. TREATMENT PLT. ❑ I ° I Method of Disposal n� Distance to nearest: Wel Foundation property Line LEACHING LINE R No. & Length.of lines - f Total length/size D kF FILTER BED, ❑ . Distance to nearest: Well"� Foundations .Property Line ' SEEPAGE PITS INr Depth �2S" size 'y�3�= Number - , . SUMPS 17Distance to nearest: Well S, �{ Foundation!00� 1 Property Line,, DISPOSAL PONDS ❑ 1 / . ,_t. / uT I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin countq ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. r `h.. *" Home owner or licensed agent's signature certifies the-following:j'I certify,that in the performance of the work for which this permit is issuod, f shall not employ any person in such manner as to become subject toworkman's compensation laws of California."Contractors hiring or sub-contracting signatuM 9� N 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." The applicant must call for all required inspections. Com late drawing on-reverse side. Signed X Title: F Date: I FOR DEPARTMENT US ONLY Application Accepted by Date 4-3--- 9 Area Pit or Grout Inspection by Dat Final Inspection by Date dditional Comments: 5tk 466-6781 ❑ Lodi 369-3621 ❑ 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 9520.1 t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO EH 13-24(REV. is 5) EH 14-28