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R 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) s. 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 q 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.;. ��© lt�- iEt�itJ7f S"7" w .. Job Address )City a Lot Size/ PM Owner's Name_!&!-.� r; Address d_ z/__��__ Phone W Contractor's Name License No. x �- __-__ - Phone 47 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION '--- SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK ®� SEWER LINES/Aed _ DISPOSAL FLD. 92,�yOP. LINE r FOUNDATION_. AGRICULTURE WELL OTHER.WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC FICATIONS ndustrial ❑ Open Bottom ❑ MMaa t a c a Dia. of Well Excav tion Dia. of Well Casing 3` El Domestic l.Private El Gravel Pack E3 Tracy Type of Casing Specifications �. ❑;.Public ,�Others�yr� El Depth of Grout Seal Type of Grout - " i � � Irrigation ---Approx. DeP!p ❑ Eastern Surface Seal Installed-by"- Repair Work Done ❑ Type of•Pump H.P State Work Done r t,• Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth ,[� Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is A , available within 200 feet.) Installation will serve: Residence_ Commercial_ Other l t Number of�liv'ing units: Number of bedrooms Character of soil to a depth of 3 feet: ' -Water table depth�.,, 4Ek�; SEPTIC TANK-. 0• Type/Mfg Capacity No. Compartments tAi PKG. TREATMENT:PLT. ❑; Method of Disposal Distance to nearest: Well Foundation r `Property Line LEACHING LIME ❑ No. & Length of lines Total length/size ' FILTER BED�. Distance to nearest: Well Foundation '`Property Line w+� SEEPAGE,PITS, w.❑ Depth Size Number " SUMPS `�` + ❑'`;Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .�,. hereby certify that I have prepared this application and that the work will be done in accdrdance with San Joaquin county ordinances, state laws, and rules and reguiations'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 wbecome subject to workman's compensation laws of California." Contractors 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..- 1l The applicant must ca or all required inspections. Complete drawing on r arse side. SignedX/_�,^ M Title: 1F M1`.., Date: FOR DEPARTMENT USE ONLY Application Accepted by,, Date Area Pit or Grout Inspection by Date _ Final Inspe n b Date �s Additional Comments � ❑ Stk 466-6781 Lodi 369-3621 -- ❑••Manteca—823-7104°- Tracy 835- Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. azetton Ave., P.O. Box 2009, Stk., CA 955201 TINFO AMOUNT DUE-- AMOUNTREMITTED CASH RECEIVED BY DATE PERMIT'NO. + it EH 13-24(REV.10183) 7Zo `� ?['y`ff�r131-t f � I/ EH 14-26 d� �