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APPLICATION FOR PERMIT �� .6: SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL IONi AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1'YEAR FROM-DATE ISSUED t : ,,...' : : T.:.. . . . (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 Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and-Regulafions of,the San Joaquin ' Local Health District. Job Address A/Lot Size PM 7" limit}/ S'j7>C Phone Address _ —�r � Phone -Owner's Name I 1 ��S 1 ��,�,/lj/ g �/j� tldress ` License No. j _ Contractor F TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT L1 OTHER EI PUMP INSTALLATION P 1e,EP AMSTEM REPAIR.E3OTHER DISTANCE TO NEAREST: SEPTIC TANK SEW fR LINES i DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS g _ INTENDED USE4 -- - --TYPE OF-WELL'"-"4PROBLEWAR EA'CONSTRUCTION-SPEC IFICATIONS— trial El Bottom ❑ Manteca Dia. of Well Excavation f-Did.;of Well Casing. V ❑ Indus �, Type of Casing �' specifications Domestic/Private ❑ Gravel Pack ❑ Tracy g `_ ,_� I ❑ Public ❑ Other ❑ Delta Depth_of_Grout-Seat Type of Grout t, F-1Irrigation ---Approx. Depth �❑ Eastern S�f ce Seal Installed by ,R State Work Done� Repair Work Done ❑ Type of Pump H.P. .b Well Destruction Ll Well Diameter Sealing Material Ito 50'1 RL � j7hl N _ 1 Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted+if public sewer is �-i available within 200lfeet.l�4/ I L .4 -•--1 t Installation M serve: Residence, Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth TANK LlType/Mfg Capacity— SEPTICNo. Compartments;� PKG. TREATMENT PLT. ❑ Method of Disposal ' f I Distance to nearest: Well Foundation Property Line ! } Total length/size LEACHING LINE ❑- No. & Length of lines r I4 FILTER BED ❑ Dis1tnce to nearest: Well Foundation Property Line - F r r �s SEEPAGE PITS - L) Deptlh Size Number f SUMPS istance to nearest: Well Foundation Property Line ' ` y w� DISPOSAL PONDS Ll - —' - i hereby-certify-that I have prepared this application and that the work will be dorie'in accordance with San Joaquin county ordinances,'state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for whichJhis permit is issued, I shall not employ any person in such manner 9as 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." i The applicant must call f r all required inspections. Complete drawing on reverse 'de. 1LDate: d �_ { Signed Title: FOR DEPARTMENT USE ONLYDate Application Accepted by z ' w �j Are � Date """"Final-In ction by Date ( Pit or Grout Inspection by I I Additional Comments: Ll Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 71 Tracy 835-6385 rP 3 ..Applicant Reiurn call copies t0_-'Environrrlental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITT ,D _CASK._ �_RECEIVE�BY: DATE _. PERMIT'NO. -- -- -INFO + EH 13-24(REV.t/651 -T*7 r EH 14-26