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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZE l 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 Ryles and Regulations of the San Joaquin t Local Health District. r Job Address _� / � _fir t 1 �� F 3'"! of S � r, City Lot Size PM �,� r � .,.�. - ,.,� y #.u.: a Fav •. ., w'y .. p' d 0"Ibox 426 ik ilf-4 Owner's Name s L Q5 Address P, `Phone _ � License Contractor L Address 1, License Nn. Phone ` TYPE OF WELL/PUMP: NEW WELL L1 WELL REPLACEMENT ❑ t DESTRUCTION ❑ IE PUMP—INSTALLATION ❑ SYSTEM REPAIR ❑,. OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE k TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C1,Open Bottom ❑ Manteca Dia. of Well Excavation f' r Dia. of Well Casing ❑ Domestic/Private ', ❑*Gravel Pack ❑ Tracy Type of Casing r?d 6 Specifications ❑ Public 'Other a! ❑ Delta Depth of Grout Seal Type of Grout I f ❑ Irrigation i -L—Approx. Depth ❑ Eastern Surface Seal Installed by ' C Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ !Well Diameter Sealing Material (top 50') St= ' Depth Filler Material (Below 50') TYPE OF:SEPTIC WORK:, NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION ❑ 1No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ]" Number of living units:, Number-o bedrooms Character.of soil to a depth'of 3 feed )- Water:table depth SEPTIC TANK .; i< -D, .Type/Mfg y CapacitNo. Compartments �. PKG. TREATMENT,PL' ❑ '1.4 /,'f `' ; \ Method .o, i�posal ~ Distance to nearest: Well c�+. Foundation Property Llne�7( rb «- } LEACHING LINE LL Total of lines i Total length/size ! FILTER BED""' _ ..311,-1j'istance to nearest: Well- Foundation )5. Property Line SEEPAGE PITS D Depth Size �' Number ' SUMPS ) ❑ Distance to.nearest:_, t Well Foundation Property Line E= DISPOSAL PONDS ❑ _ r ' 1 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 District. 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 ln%ihe performance of the work for which this permit is issued,I shall employ:persons.subject to workman's compensa- tion lapliof California." • , csl I The apI far a requir in ctions. plate drawing on reverse side. ..e A U r Signed Title: J�Y/ /� '4...::: t+ Date: �1 FOR DEPARTMENT USE ONLY —Applic`ation Accepted'by"'�"� " "" - ` Date ' * Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 _ ❑ Tracy� Applicant- Return all copies to: EnvironmentaLHealth Permit/Services 1601 f-Hazelton_ Ave., P.O7Box 2009,FEE 5tk., CA 95241 FINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE11MIT"N0. + EH 13-24(REV.I/a51 - - - - • EH 14-26 �`-