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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �f p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „ 4 (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 a PP licatinn 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. �' ®dry iL1,(* I � . W, Job Address _ City Lot Size PM �� Owner's Name V"✓ �� AddressC.//J0111 Phone � Co �ntractor Atldress �`at I� I NC � License Ntfr-�/�J�L Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK TL '— SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC IFICATI N ❑ Ind lar ❑ Open tto' ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing omesticlPrivate ravel Pack El T e of Casin ^�' �Y YP 9 Specifications I'1 Public L1 Other . el alta Depth of Grout Seal �? T pe of Grout _ I I'Irrigation �_._Approx. Dep I Eastern Surface Seal Installed by Repair Work Done 1� Type of Pumpr H.P. State Work Done # Well Destruction O Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I1 RFPAIR/ADDITION l I DESTRUCTION 1-1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms G Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE 0' No. & Length of lines Total length/size � � FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ; DISPOSAL PONDS ❑ ' a 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 ' rules and regulations of the San Joaquin Local Health Di$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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature fj 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- F tion laws of California." r, The applican c Ifo Ir re in pec ons. Complete drawing a sijile. Signed X Title: �J ,V/ Date: ` U•/– �"" z FOR DEPARTMENT USE ONLY II Application Accepted by Date Area i Pit or rout nspection b Date f / Final Inspection b v Data�� 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, Sik., CA 95201 w FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. INFO CASH +"EH 14-281REV,tin51 0 —})