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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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 S7a(54'�-70AJ Lot Size PM Owner's Name S040-42%4D Address - r �-- -- Phone i Contractor F4r!Y n Address 7 AJ. AG'-1- License No.424_;-76-7G p X 397 TYPE OF WELL/PUMP: _ NEW WELL 17�' ,0 , WELL REPLACEMENT ElDESTRUCTION L-1I PUMP INSTALLATION ❑ TSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL a PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing.. Specifications F] Public n Other n Delta Depth of Grout Seal Type of Grout 1 I I Irrigation --Approx. Depth I I Eastarn Surface Seal Installed by i Repair Work Dane C Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION - DESTRUCTION [ I (No se tics stem permitted if p y' p public sewer is available within 200 feet.) G Installation will serve: Residence Commercial_ Other i Number of living units: _L Number of bedrooms Y I Character of soil to a depth of 3 feet: ��►rf `• " _. Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit _1 10 a p y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well AJIA — Foundation Al Property Line 3 LEACHING LINE Eq No. $ Length of lines /y S Total length/size /S- of— FILTER 1 �X z FILTER BED El Distance to nearest:_'"Vl/eIF—X IFoundation d�� _ Property Line S� SEEPAGE PITS r l�r Depth Size Number / SUMPS �El k Distance-to nearest: "— Well _-Foundation f O � Property Line_ 7 � DISPOSAL PONDS ❑ S ` I hereby certify that I have prepared this application and that the work will be&ne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D%trict. ' 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 4 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature t-- certifies the following: "I certify that in the performance of the work fo,- r wfiich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." :�---�- - -. - -- .��.� ' The applicant must call for all required ins=c ions. Complete drawing on reverse side. _ Signed X Title: Date, /Z -174 a2Z F. DEPARTMENT USE ONLY Application Accepted by Date _ Area ; Pit or Grout Inspection by Date Final Inspection by -Date ^t}� 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK i1 DATE PERMI.T•NO. i.EH 14-241REV.tiiNal _ EH 14-28 -O �'^�