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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 i Local Health District. `/ / Job Address Ci Lot Size Y.7 PM Owner's Na e dr s _�. f � phflne Contract Address License No. Z�y Phone.Ml!1 TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ ;" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF WELL PROBLEM" A _,"CONSTRUCTION SPECIFICATIONS —0 Industrial ❑ Open Bottom """❑ eca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications I7 Public ❑ Other F7 Delta Depth of Grout Seal Type of Grout I I Irrigation prox. Depth 11 Eastern Surface Seal Installed by ; Repair Work Done 0 V of Pump H.P. State Work Done Well Destruction ` Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE CFF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is !'N y \ t i available within 200 feet.) Installation will serve: Residence `� Commercial__ Other ' Number,of living units: -#___— Number of bedrooms f s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg r f Capacit �A4'� No`Compartments PKG. TREATMENT PLT. ❑., Method of Disposal Distance to nearest: Well Foundation Property Line .. LEACHING LINE L✓I No. & Length of fines S — Total Length/size ,p w FILTER BED ❑ Distance to nearest: Well �.-�_ Foundation Property Line :57 r __ SEEPAGE PITS i I Depth l Size ' S ��J .� Number a SUMPS Distance to nearest: Well .:-_ Foundation Property Line _ DISPOSAL PONDS s❑ z ( _` "' r; I hereby certify that I have prepared this application and that the work_willbe done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local-Health District- '" "'`"�_"_- i .L ii 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 employ persons subject to workman's compensa- tion laws of California The applicant call far all requir inspections. Complete drawing on reverse side. Signed X Title. Date: FOR DEPA TMENT USE ONLY ApplVigation Accepted by Data Area P' rout I ctiori by "" Date 'Final Inspection by Date/ Additional Comments: s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ..EH 13-24 1REV.t/H sl ��er 1, EH 14.28 � 99��P