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i . APPLICATION FOR PERMIT d.J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. v Job Address ity Lot Size_2_1"M d JOwner's Name s "Address °-� �f Phone Contractor• Address w License No.�� y Phone TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ S M REPAIR ❑ OTHER ❑ DISTANCE-TO NEAREST: SEPTIC TANK S WER LI DISPOSAL. FLD. PROP. LINE + t FOUNDATION A IC TURE WELL . OTHER�WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM REA CONSTRUCTION SPECIFICATIONS y 17 Industrial i ~'L Open Bottom ❑ Ma ca Dia. of Well Excavation 1 r Dia. of Well Casing ❑ Domestic/Private ; f ❑ Gravel Pack ❑ acy Type of Casing Specifications s . E'1'Public f Other Delta De Depth of Grout Seal P Type of Grout I I;Irrigation Approx. Depth I Eastern Surface Seal Installed by rer Repair Work Done - ❑jK2Type of Pump H. State Work Done Well Destruction ❑ Well Diameter Sea ng Material (top 50'1 �•-/ Depth Filler Material f Balo 50') r` TYPE OF SEPTIC WORK:' NEW INSTAL TION 1'1 REPAIR/ADDITION DESTRUCTION ! I (No septic system permitted if public sewer is Q _ T-' available within 200 feet.► Ihstaflation will serve: Residence Commercial ther 4 { Number of living units: Number of droom Character of soil to a depth of 3 feet:- [ ,.t` ` Water table depth i 1 4 SEPTIC TANK r'��❑ Type/Mfg r Capacity No Compartments � . -�;PKG. TREATMENT PLT, ❑- A {s Method of Disposal V_ distance to nearest:• 'WellFoundatiori '""" Property Line e r "I # LEACHING LINE ` ❑ No. & Length of lines Teal length/size FILTER BED'''' # ; ❑ Distance to nearest: Well Foundation 1�L)< Property Line i Jr *max.... SEEPAGE'PITS i 11 Depth- Size N ber SUMPS 4 f 0 Distance to n r st: Well !19�— Foundation Property Line ` DISPOSAL PONDS C7 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 Joaquih.Local Health District. qq Home owner or Iicensed-agent's signature certifies-the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not I 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, tion laws of California." 1 shall employ persons subject to workman's compansa- n .� 1 The applicant stAall for ired in ctions Complete drawing on reverse side. Signed X Title: 4 r Date: FOR DEPARTMENT`USE ONLY; Application Accepted by ' D Z 15-111. � + Area Pit or Grout Inspection by � Date Final Inspection by Date 1 g . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 1 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASHEIRECEIVED BY DATE PERMIT'NO. �.+ EH•13.241REV:'inns9:*^^"--"-'- EH 14-26 �' . ,..�I., _'Z...(j6„ ��:- I