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fell Z--, - x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone 1209) 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Addresses '` — City dLetLaaa— Lot Size PM Phone 1 Owner's Name N Address-?I?(, r ~ Contractor Address ��sI_ �1 �-a, License No.I�C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 15OTHER ❑ 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'Q'DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications A 1 I-1 Public F] Other CJ Delta Depth of Grout Seal Type of Grout _- 7w I I Irrigation 3 —Approx. Depth I EI Eastern Surface Seal Installed by - Repair Work.Done L� Type of Pump .. H.P. State Work Done I Weil Destruction ❑ Well Diameter Sealing Material (top 50') T-. Depths . Filter Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION l I DESTRUCTION I I (No septic.system permitted if public sewer is available within 200 feet.) a Installation will serve: Residence Commercial_.— Other t *` ,Number of living units: Number of bedrooms Character of soil to a depth of'3 feet: i Water table depth ]1 \' SEPTIC TANK_. ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT ❑ i Method of Disposal �.. _- " Distance to nearest: INe1t "Founeiati0h^�- - --Prope"rty tine- —` F. -LEACHING LINE 0 No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Size Number SUMPS Cl Distance to nearest: Well 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. I.'f 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 f the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican ust cal for all requirerequiro inspections. Complete drawing on reverse side. Signed X �"Fitle: Date: — FOR PARTMENT USE ONLY 't Application Accepted by Date—J� ( Area T i cA Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT*NO. INFO I ♦.EH13-24tREV.I/Rs) EH 14-2e :h