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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) 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. ' Job Address /� '� City. L Size �l PM Owner's NameAddress Phone i Q I Contractor_ Address) �t __"E)cense Nt Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER,171 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" r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy 1 Type of Casing Specifications (� 1 r 171 Public ❑ Other _ Cl Delta t Depth of Grout Seal Type of Grout I I Irrigation _,.Approx. Depth 1.1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑. Well Diameter Sealing Material (top 501 A Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION X DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ,Residence_ Commercial_ Other . . Number of living units: _L_ Number of b dr ms_ - / Character of soil to a depth of 3 feet: T Water table depth p SEPTIC TANK ❑ Type/Mfg CAar_.ity - No. Compartments r PKG. TREATMENT PLT. O e: Method of Disposal v it Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines. "" 9'-0 Total length/size , � �_l - 1 � FILTER BED ❑` Distance to nearest: Well� Foundation ZCQ 4-*' Property Line I 4 I' SEEPAGE PITS Depth Size Number SUMPS C71 Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I hereby certify that f 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. V 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 of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California."' if s vt The app727F; ll f r II required inspections. Complete drawing on revers side. i Signed r, G—L 1c.Ek Title: -- Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area ! p p Pit or Grout Inspection by Date Final Inspection by l�%c..�c�-� Date ` 09 Additional Comments: ❑ Stk 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 INFO ��////A77N40UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.t i H 5Y /L �t.a.J (d"�� a EH 14-28 f