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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) 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 7 G City.-.-.5Lot Size PM Owner's Name >�'`�� /� ��" Address // Q ��` Phone r Contractor Address alf, License No.��os7 0� Phone TYPE OF WELL',PUMP:- `' NEW WELL`"❑ .`--A WELL HL:FLACEMENTAr DESTRUCTION ❑ PUMP INSTALLATION" SYSTEVREPAIR ❑ OTHF,�i ❑ i " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PRO P..LINE- /✓ FOUNDATION --,'--AGRICULTURE W.ELL OTHER WELL�t PITS/SUMPS I r ] e INTENDED USE ?TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATION§ �f ❑ Industrial ❑ Open.bottom ❑ Manteca Dia. of.Well Excavation /Z Irr _ Dia. of Well Casing AD Gravel Pack ❑ Tracy Type of Casing Ole— Specifications JF ` f'i Pubtic Cl Other Ll Delta Depth.of Grout Seal Type of Grout I 1 Irrigation IApprox. Depth I I Eastern Surface Seal Installed by - Repair Work Done L7_:;�ype"of Pump f State Work Done_ Well Destruction ❑. Well Diameter : Sealing Material,ftop 50'1 Depth Fiber Material IBe_loW 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1" RFPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence_ Commercial—Other r Number of living units:"° Number of bedrooms Character of soil to a depth of 3 feet: ° � a r % Water table depth `fN Capacif No. Compartments SEPTIC TANK ❑ T.ype/Mfg Y PKG. TREATMENT PLT. ❑ v'" t.` Method of Disposal ` Distance to Barest� Well Faundatio F I Property Line LEACHING LINE ❑ No.-&-Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS { I Depth Size t Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s r l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ari-c rules and regulations of the San Joaquin Local Health District.' T ' 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." Contractors 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." The applicant ec I req tions. Complete drawing on raver Signed X itle: Date: t -----f 7 FOR DEPARTMENT USE ONLY Application Accepted by Date ` Area ' f Pit Grout Inspection by M V ate ��/1 Final Inspection by ►�--�� Date Additional Comments: C tr I' ❑ Stk 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 95201 s FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT"NO. INFO C CASH ♦.EH13-24 IREV.t/x 51 VS !S �1X3-3& --;L- EH 14-28 "-