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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 Local Health District. On Job Address Cit 1 7 City Lot Size ` PM 40, t , i-_, r L Owner's Nam t �Y1 Address !. z�ldl�A"Phone%133— Conirac! r Address EWA �t� ! j License No i 3o[CO Phone6 —1 15 TYPE OF WELL/PUMP. NEW WELL ❑ a,_-WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES+ DISPOSAL FLD. 'PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL •: PROBLEM AREA CONSTRUCTIONtiSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s L1 Domestic/Private ❑ Gravel Pack ❑Tracy . "Type of Casing_ A Specifications s .� (-I Public Cl Other ❑ Delta Depth of,Grout SeLalP-_ ii ""� Type of Grout i I I Irrigation ' _Approx. Depth I 1 Eastern Surface Sea! Installed by �'� r _ Repair Work Done ❑ Type of Pump H.P. State Work Ron ,. Well Destruction ❑ Well Diameter Seali�g,Mate(ial (top 50'1 _ Depth IFiller Material (Below 50'1 "x'*-^ TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted it public sewer is j available within 200 feet.) J installation will serve: Residence Commercial Other Number,of living units: Number edroom a4 ! `� Character of sail to a depth of 3 feet: _ j f ! Water table depth_114o + SEPTIC TANK LTJ'Type/Mfg Capacity o_�. No. Compartments PKG. TREATMENT PLT'❑'^--� i �,. r F �c :. Method of Disposal s Distance to-nearest: Well 50 Fouridation r Property Line___�s LEACHING ONE (P- No. & Length of lines Total length/size O / f_ FILTER BED ❑ Distance to nearest: Well s501' Foundation D Property Line SEEPAGEPITS? f�Depth J Size �_� Number i SUMPS / 1 0 Distance to nearest: Well 14W Foundation Property Line DISPOSAL PONDS' ❑ 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 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, I shall employ persons subject to workman's compensa- tion laws of`California." The applicant mus 1 all for all roguired inspections. Complete drawing on reverse ide. Signed X Title: �r Date: 13THQ, n 7 FOR DEPARTMENT USE ONLY Application Accepted by � Date _ Area or Grout Inspection b ate Final Inspection by Date,/ Additional Comments: ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. i EH 14-26 l .. l