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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone-f209) 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. } .* �� City 3 `..� Lot Size _:5� PM Job Address Address Phone , Owner's Name - - -- &�f9T �L1111—, Phone �` 3 Address License No. ��f� �� rZ Con ra Cot` = WELL RUPLA _EMENT`❑_�.._ DESTRI'JCTION`❑—•"" TYPE OF WELL/PUMP': 8 NEW VIIELL�? ._.-._m_�..-. . . , PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ J DISTANCE TO NEAREST: SEPTIC TANK— SEWER LINES DISPOSAL FLD. PROP. LINE _- --FOUNDATJON_� AGRJCULT.U.RE WELL OTHER WELL _ PITS/SUMP5 � CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA � � st Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation !� -', � Type of Casing % Specifications Domestic/Private ravel Pack ❑ Tracy g 10 Type of Grout t�t2 I'1 Public I� Other FI Delta Depth of Grout Seal YP _ � i I Irrigation 1 ®W,,Approx. Depth t 1 Eastern Surface Seal tnstalled by ` Repair Work Donee Type of Pump H.P. _•State Work Done ; t Well Destruction 0 Well Diameter Sealing Material (top 501 Filler Material (Below 50'i Depth �1 TYPE OF-SEPTIC W ORK: -NEW INSTALLATION Il REPAIR/ADDITION ! I DESTRUCTION I I ava septic system permitted it public sewer is r ilable within 200.teet.l iervJi Installation will avaResidence_'Commercial_ Other t Number of livini,units: Number of bedrooms Character of soils to a depth of 3 feet: Wa a depth " SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t Method of Disposal PKG. TREATMENT PLT. ❑ 3 i "Distance to nearest: Well -� oundation , Property Line LEACHING LINE eR I 'No. &Le�gth o s Tota! length/size $ FILTER BED F/f" ❑ �Disfan :o-nearest: Wel! Foundation Property Line i 1 I ' SEEPAGE PITS l I I Depth � Size umber 1 SUMPS ❑ Distance to nearest: Well Foundation._ ,h Property Line �( f b U, D AL PONDSJt ❑ 1 I hereby certify that I have prepared this appkcstion and-that the work will be done in.4 4cordarnce 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 theme 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 Califomis., Contractor's hiring or sub contracting signature r certifies the following: "I certify that in the performance of ibe work for which this permit is issued, I.shall employ.persons subject to workman's compensa- tion laws of California." } h The applicant require tions. Complete,drawing on re7 05 Signed X 1 Title: Date: ` 4 FOR REP RTNIENT USE ONLY �,,� Date . Area Application Accepted by "` �� J j G Pit or Grout Inspe tion by'5� Date!-�� Final Inspection by i Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-085 ^^-�-- Applicant- Return nn al, l copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St 3201"- .FEE. AMOUNT DUE AMOUNT REMITTED " �K RECEIVED BY DATE PERMIT'NO. INFO CASH""- �ry F +.EH 13.24(REV.s/1151 t U�=�� r e� �� •�µ�' EH 14-2e