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r � a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 City Lo Size PM f r Owner's Nam Address Phone Contract _ Address&Apc 7271V�W- License hon TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE `TYPE 01;,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing `# ❑ Domestic/Private ❑ Gravel Pac(,, 0 Tracy Type of Casing Specifications 11 Public -1 Other's Cl Delta Depth of Grout Seal Type of Grout I I Irrigation - ._.Approx Depth I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump"- 1- �, H.P. State Work Done_ ' Well Destruction ❑ Well Diameter, Sealing Material Itop 50') _ I -Depth ler I4aterial Welow 50'1 TYPE OF SEPTIC WORK:_,,NEW INSTALLATION 1.1 Q1EPAI9ADOlTtON)< DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial F 9ther / F Number of;living units: _/__ Number of r rtis # _ !l Character of soil to a depth of 3 feet: 4.�rv"�--� Water table depth ' ».n SEPTIC TANK -' Type/Mfg "fir r Capacity No. Compartments PKG. TREATMENT PLT. 0 _ �. ; Method of Disposal Distance to nearest:' Well Foundation Property Line .� / LEACHING LINE No. & Length of lines ``f Total length/size Z FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS � Depth Size � --' '"- _ Number SUMPS ❑ Distance to nearest:.. —WeIL Foundation�� Property Line ✓ DISPOSAL PONDS ❑ i hereby certify that I have prepared this application and that ihwork will be-done-in.accordance with San Joaquin county ordinances, state laws and 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 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." s The applicant cal! for al! a ire 'nspections. Complete drawing on reverse sl e. -, L f � Signed X Title: - '; Dater P FOR DEPARTMENT USE ONLY pplication Accepted by -- — - -- -_-Date -- r -11--Area C/ P t or Grout inspection by a e - final Inspection by ► .��1Datq� 7 Additional Comments: , - — - 0 Stk 466-6781 ❑ Lodi 369-3621 C7 Manteca 823-7104 - 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r F INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT NO. +.EH 1324 IFIEV.$1 x 51 Eli 14-26 t