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APPLICATION FOR PERMIT SAN JOAQU€N 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) Application is he+eby 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. n Job Address City Lot Size PM 1 Address, Phone 03 Owner's Name i t Contractor _ _ _s_ .r -_i. _ -�....„.•1..� �� -,- �.- - � ress License No. TYPE OF WELL/PUMP: T NEW W L ❑ ELL REPLACEMENT ❑ _ 'ti",. DESTRUCTION ❑;' r C }:r I PUMP INSTALLATION L) SY EM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK`. SEWER LI E DISPOSAL FLD. s PROP. UNE FOUNDATION r AGRICUL E WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS © industrial ❑ Open Bottoms ❑ Manteca Dia. of Well Excavation J •t Dia, of Well Casing 4 ❑ Trac Type of Casing J. Specifications \ i Ll Domestic/Private ❑ Gravel Pack �., y I1 Public 171 Other F1Delta Depth.of Grout Seal Type of Grout I I Irrigation _..Approx. Depth t l Eas rn Surface Seal installed by• - (s. Repair Work Done ❑ Type of Pump H.P, ___ State- Work Done J " *�WeII Destruction ❑ Well Diameter Sealing Material (top 50'1 �"" 1' Depth Filler Material (Below 501 _-- i TYPE. OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDI N l I STRUCTION l I (No septic system.permitted if public sew s �. '�.., Mable within 200 feet._► ' Installation will serve: ResidenceCommercial_ Other i �G ✓ 7�'' L�/ I ,Number of living units: Number'of bedrooms 3 J3 Character of soil to a depth of 3 feet: Water to a depth ,A SEPTIC TANK ❑ Type/Mfg - Capacity NolCompartments ,e- PKG. TREATMENT PLT. 0 Method df Dispos Y Distance to nearest: Well oundation J 40 Property Line `'. n `" . ^ LEACHING LINE ❑ No. & Length of lines TotaE length/siza<<'.' FILTER BED ❑ Distance to nearest: Well _ Fo ndation _Z� Property Line SEEPAGE PITS 1 I Depth-12 Size Number `SUMPS ❑ Distance to ni rest- ,Well _ Foundation� 'Property Line f 1 T 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 i ,erules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: 1 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 I 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." 1 I ', The applicant t call for all r ed inspe ions. Complete-drawing on reverse side. - (1 *4 — f . Signed X Title: - Date: f r . i FOR DEPARTMENT USE ONLY.. 11 n Application Accepted by Date y V Area Pit or Grout Inspection by bate Final Inspection by Date r Additional Comments: 6e C,r✓ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104' ❑ Tracy 835-6385 l , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t s FEELAMUNT DUE AMOUNT REMITTED CK 9 CAS+! RECEIVED BY DATE PERMIT'NO. l INFO .J--*IH -24•IREV-V✓.8.51 �,...w....� -.,...�•..-••--�....�--� EH 14-26