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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 i made in compliance with San Joaquin County Ordinance No. 649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -1-1--T> 70 1�)+A"U I _ City X—e2 t Lot Size..� p PM „ Owner's Name {�J1 t' '�i1L f'11i YI S�1 v► _ Address+ Phone " —Contractor Address'(i'� c � 3! i'cerise No: q 1v- 2N Phone . ' `c .TYPE OF WELL/PUMP: _ NEW WELL �C - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION� SYSTEM REPAIR ❑ OTHERS❑ 7 DISTANCE TO NEAREST: SEPTIC TANK (i SEWER LINES "` DISPOSAL FLD.I PROP. LINE S5! FOUNDATION _ _� f AGRICULTURE WELL OTHER WELL PITS/SUMPS j ! r---- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S �� 6 Ll � ,)KOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � i omestic/Private ❑ Gravel Pack. -� - .❑,Tracy---�..�.,.. --Type of Casing. r �-�.- Specifications. �. .,. I"1 Public ❑ OtPer ❑ Delta Depth of Grout Seal `h 'Ef r , Ty'e of Grout .G mit Fi I I Irrigation �`��_App x.Depth RI.]Yastem' - Surfaoa Seal Installed by IRepair Work'done--❑ Type of Pump H.P. . S9--n State Work Done_ # 'Weld struction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF`SFPTIC`WORf(:-••uNEW INSTALLATION I1• REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) I' ' Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to�<adepth of. feet: Water table depth SEPTIC1TANK ❑ Type,/Mfg Capacity No. Compartments s PKG.JREATMENT PLT. ❑ Method of Disposal R P y.A ` Distance to nearest: Well Foundation = Property Line t t � t a LEACHING LINE r' ❑ No..&`Length of lines Total length/size k FILTER BED t• ❑ Distance to nearest: Well Foundation Property Line t f — SEEPAGE PITS 'y .hl Dapth. Size Number .1 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1-C3 t �- ,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 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 petmit,,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: "1 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 must call for all required inspectiogs. Complete drawing on reverse side. -a- Signed X ar i Title: Date: FOR DEPARTMENT USE ONLY # Application Accepted by Date r Area Pit or Grout Inspection by < Dat Final Inspection by Date Additional Comments:. Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 , Applicant- Return all copies to: Environmental Hbalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2OD9, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. i INFO CASH ♦ EH 13-24 tREV.tike] // . EH 14-26 fP