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APPLICATION FOR PERMIT hl- 1.2-7 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. t_. AAA.--- `1 � '� i C IS/F � � / /'1 T i� N i� f':+.. L Al .+91 L"r� liAn+ C:,n S .Q --0 9C� pM Owner's Name YUA L= Address —9 A O 9TM 3 _ Phone ;z Contractor's Name License No. Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .—PUMP -INSTALLATION ❑ SYSTEM REPAIR D—i r'- OTHER El DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FL D. PROP. LINE is FOUNDATION I AGRICULTURE WELL OTHER WELLI I PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEM AREA -CONSTRUCTION SPECIFICATIONS ❑ Industrial # ❑,Open Bottom 1 ❑ Manteca, Dia.,. of Well Excav9tion t' Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack 4 s❑ Tracy r Type of Casing Y Specifications ❑ Public , ❑ Other \ ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work [Done F Well Destruction ❑ Well Diameter Sealing Material (top 501 _ —Depth--- — Filler Materiai iBelow 501 "-.y } ' TY•PE'OFSEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION• ❑ ';DESTRUCTION ❑ (No septic system permitted if public sewer is, f : available within 200 feet.) 1 Installation will serve: Residence _ Commercial. _ Other � �"'s "l i Number dliving units: L Number of bedrooms Character of soil to a depth of '3 feet: cs" .4 +""" `�"'"^� � "'�Water table depth' SEPTIC TANK .,-Yi( Type/Mfg Pg 4,RJ-C Capacity /Z(I�jn i• No. Compartments ' PKG, TREATMENT PLT. ❑ I 1" ` s �' Method of Disposal i Distance to nearest: Well iciC� r Foundation Property Line LEACHING LINE No. & Length o�s Total length/size! FILTER BED ❑ Distanc to nearest: Well Foundation Property Line r , SEEPAGE PITS tDepth +�f Size 3 3 r .'Number, SUMPS df Distance to nearest: Well Foun l dation %OQ�� Property Line �0 DISPOSAL PONDS )] .n s' 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 rulesland regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I certify that I the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature R certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emp persons subject to workman's compensa tion laws of California." i F � The lapplicant must call for all required inspections. Complete drawing on reverse side. Signed X t ( Title: f Date: FOR DEPARTM USE ONLY Application Accepted by 4 Date / r� Area RJj N Z 0 f Grout Inspection by Date l " Fi Inspection by to Additional Comments: ❑ 5tk 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 VA IFEENFO AMOUNT DUE AMOUNT REMITTED? CASH RECEIVED BY �cDATE .S PERMIT"NO. + EH W241AEv. 101831 1. -1;. � o 1-A_'7 , O 1\(� -1 C'�3 '-i -1 �8 EK 142fi