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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTHDISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 " PERMIT EXPIRES YYEAR 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 Ordina a No 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the made in compliance with San Joa uin County San Joaquin Local Health District. r ■ Cit Lot Size PM Job Address ' c,f t AddressIK f / PhoneSne -,34&-s o d q '� Owner's Name Contract rAddresLicense No fZZG P �O TYPE OF WELL/PUMP: NEW WELL 1-1WELLREPLACEMENT ❑ DESTRUCTION Ll -- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:..SEPTIC TANK SEWER LINES PROP. LINE DISPOSAL FLD. � � FOUNDATION AGRICULTURE WELL OTHER WELL 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications T e of Grout 3 _ {1 Public (� Other ❑ Delta Depth of Grout Seal yp I I Irrigation Approx. Depth t i Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P. - State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATiON.Nv REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Instaliation wilt-serve: Residence-�C-ommerciai-�__ -'Other !+ *� Number of living units: � Number of bed s 'atLt, '� f � q _ _ �--�- .. .. ._— s --- - -- Water table depth Character of soil to a depth of 3 feet:t SEPTIC TAN3CJ' !,Type/Mfg Capacity-/&-00No. Compartments PKG. TREATMENT PLT.-❑1�_ / t Method of Disposal Distance to nearest: Well Foundation _..�� Property Line i LEACHING LINE No. & Length of lines Tota! length/size / r C � ` FILTER ED -�+.�'!�i,+ 0, Distance two neafe&t:4-', Well � Foundation_.-.��.__ Property Line i D ` . ' Number _ SEEPAGE PITS E ' Depth 1 Size- E_ �. ��- Yr_SUMPS--"IG, L Dlsta�lce to nearest: Well /� F undation Property Line -.a" DISPOSAL PON_D5 ❑ _ °-, �• - hereby certify that,(have prepared this application and that the work will be�offetin accordance with:San Joaquin cbu`nty'ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. N'..h 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." Contractors 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." The applicant u call for all regu a 'nspecctions. Complete drawing on reverss' `[ Signed X - .y Title: \M - Date: FOR DEPARTMENT USE ONLY r � I v Area Date s Application Accepted by t or Grout Inspect!on by Date - Final Inspection by Date Additional Comments: ❑ Stk 466-6781 •❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT ND.r INFO Q ( �ur! t Chowr [3 1 +.EH 13-24 iREV.1/n 5) EH 14-26 f