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APPLICATION FOR PERMIT 3�y( ,t t ' 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. DRA Jou muulubb �- "�" •.� - �-. , -_. ____ ^ Owner's Name I`� ° Al✓'' %�s Address Jt`✓x�'f�None a p Contractor ` ._" � Address 0 7 d 4 = c'� }�/�C License No. �4(J' 5�r�- Phone TYPE OF WELL/PUMP: NEW WEL�>< WELL REPLACEMENT ❑ DESTRUCTION ❑ INFO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ CASH DISTANCE TO NEAREST: SEPTIC TANK EWER LINES OSAL FLD. - 11MP. LINE FOUNDATION AGRICULTURE WELL HER WELL MPS_' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation—43 Dia. of Well Casing 6omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Q�� Specifications i0l e, F1 Public ❑ Other ❑ Delta Depth of Grout Seal 5t2 T e of Grout 17 I I Irrigation y Approx. Depth I I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State W e _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (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 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 Distance to n rest: Well Foundation Propert - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welloundation Property Line SEEPAGE PITS I I Depth Siz Number SUMPS Ll Distance to nearest: ell Foundation 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 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 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 a." The applicant mn Calif;t 1 f asrequire inspe 5' . omplete drawing on reverse side. Signed Application Accepted by Pit or Grout Inspection by Additinnal Comments: f Title: Date: ' .4 /7 R DEPARTMENT USE ONLY § ��.�..... Date C? Area Date �� ! Final Inspection by ❑ 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 ♦.£H 13-241REV. t/x5 EH 14-26 Date FEE DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT INO. INFO C,4MOUNT CASH