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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Weil/pump and the Rules and Regulations of the San Joaquin $ Local Health District. T a w I T � � 1 � `rCity �v� � of Size PM Job Address Owner's Name �•�r�. Y Lem Addressel"IAI � Phone R~ �Q 5ttlr/� License Not 11i Phone Contractor's'Name TYPE OF WELL/PUMP.r NEW WELL Ll WELL REPLACEMENT Q DESTRUCTION El ` i K, PU- INSTALLATION'❑ SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWEfl LINES DISPOSAL FLD. PROP. LINE FOUNDATION; AGRICULTURE WELL- OTHER WELLI PITS/SUMPS qk INTENDED USE TYPE-OF WELL PROBLEM AREA,VJ,CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca—Dia-of Well Excavation ' Dia. of Well Casing f L1 Domestic/Private ❑ Gravel Pack ❑ Tracy ype of C sing_ t" Specifications ❑ Public ❑ Other 11Delta Depth of Grout seal �' Type of Grout I ❑ Irrigation ---Approx. Depth O EasternS,urface Ses1 Installed byi ! Repair Work Done ❑ Type of Pump �`� I H.P. State Work"Done Well Destruction ❑ •Well Diameter - Sealing Material (top 50'1 `4 Depth Filler Material (Below 50'p : 4 TYPE OF SEPTIC WORK:. NEW INSTALLATION l; REPAIR/ADDITION E3DESTRUCTION'❑ (No septic system permitted if public sewer is '' .,i - --— -- available within 200 feet.) Installation will serve: R 'dence- Commerci l_ Other ai Number of living units: t Number of bedrooms� t 3��. Character of soil to a4depth of 3 feet: Water table depth SEPTIC TANK E] Type/Mfg N � Capacity No. Compartments PKG. TREATMENT PLT. ❑ � w ' Method of Disposal ,�--�., . 7 Property Line Distant;to nearest: Well� Foundation P � LEACHING LINE "£ i No. &-L nngth of lines B f' Tota length/size FILTER BED E]. Distence•to nearest: We Foundation Property Line " I SEEPAGE PITS Ll Depth Depth Size SUMPS # ❑ Distance to nearest: Well Foundation a .1 Property Line DISPOSAL PONDS I hereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state l I rules and regulations of the San Joaquin Local Health District. I 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." ploy Contractor's hiring c 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- I tion laws of California:" I The applicant m c r fall re i d '.spections. Complete drawing on reverse side. Date: Signed Title: ♦ '.t t � FOR DEPARTMENT t#5E ONLY � 1 Area Application Accepted by �.R$F�� - Date "� - Date�9^ � Final Inspection by Date �► P o Grout Inspection by 1 _ Additional Comments: ❑-StV 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 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. INFO �. - U + EH 13-24 tREV.101831 Dv • ��`O / o �I� EN 14-26 !