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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) I 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 f' made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/purnp and the Rules and Regulations of the San Joaquin Local Health District. Job Address i Z f V4!5J 6N,, City Lot Siz PM J� , f Owner's Name ?address ZLIFy Phone �� Contractor i� AddressLicense No Phone TYPE OF WELL/PUMP: �� NEW WELL C1WELL REPLACEMENT.0 DESTRUCTION 11 PUMP INSTALLATION'❑.tee 'WSYSTE�M R AIR,❑ OTHER ❑. k I x f DISTANCE TO NEAREST:.SEPTIC.TANK SEWER LINESDISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Dia. of Well Casin ❑ Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation 9 € ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public F'Other F Delta Depth of Grout Seal Type of Grout r I 1 Irrigation J-1-Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done Cl Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 'Sealing Material (top 501 t Depth Filler Material (Below 50') { TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION l 1 DESTRUCTION I I lNo septic system permitted if public sewer is ' r ` Ip available within 200 feet.) � Installation will serve: Res'"denc�Commercial _ Other t G i \ Number of living units: Number of bedrooms 4 r Character of soil to a depth of 3 feet: GL SS /I.'.-Water table depth d SEPTIC TANK. ❑r ❑ Method of DispSal:Type/Mfg ��- Capacity A! No. Compartments pr PKGTREATMENT PLT. � , t, h Distance to nearest: Well-/ — Foundation Property Line LEACHING LINE ❑ No:�& Length of lines �•� # Tptal length/size FILTER BED L1 Distance to.nearest: Well Foundation ..-.__.-- Property Line SEEPAGE PITS l l� Depth z Size s Number _. SUMPS 'Ll Distance to nearest:_-_-Well !- r Foundation-- Property Line j DISPOSAL PONDS -❑; <.'" I hereby certify that I have prepared this application and that the work will be done in accordance withi:San Joaquin county ordinances, state laws, and rules and regulations of the]San Joaquin Local Health District. Home owner or licensed agent's'signatuPe certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any personin 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,I shall employ persons subject to workman's compensa- tion laws of California.- s The applicant must call for all required inspections. Complete drawing on reverse side. „ i Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by -". Date Area _ / �. Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: fl'"_ 1 f f"` „'`J Cr 1�1� � `' r ❑ 5tk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 �O� ��r,pj 0 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bbx 2009, Stk., CA 95201 FEE XMOUNT DUE AMOUNT REMITTED "" CK RECEIVED BY '�" DATE PERMIT'NO. INFO EH 4 IREV.I K5) 7 // yCfA�\5H EH 14-28 �71 �� X/1