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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i601 E.•HAZELTON AVE., STOCKTON, CAI. `(_ V Telephone 1209) 466-6781 I Y{ PERMIT EXPIRES TYEAR FROM DATE ISSUED V 1 (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 F made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. F Job Address City Lot Size {a O a Owner's Name ,Address ' = -r t ' Phone Contractorazyess nse No. Phone ` TYPE OF WELL/PUMP: NEW WELL O _ WELL REPLACEMENT ❑ DESTRUCTION CT ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ =OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD. s PROP. LINT; FOUNDATION AGRICULTURE WELL OTHER WELL f PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation f Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑-Tracy Type of Casing t Specifications h� ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth I Eastern x Surface Seal Installed by i r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 -REPAIR/ADDITION I I DESTRUCTIQUA Mo septic system permitted if public sewer is T �" available within 200 feet.I Installation will serve: Residence "moo e. Ot t Number of living units: . N bei�!'F e r� Character of soil to a depth of 3 feet: Ial halve exph Water table depth UU v. ' SEPTIC TANK El Type/Mf g a No.iCompartments PKG. TREATMENT PLT, ❑ war- being completed or inspected Method of Disposal Distance t4b6nvirom, %rital HeieftTFrL fftlan Property 6nJ LEACHING LINE ❑ No. & Length of lines `' Total length/size- FILTER BED ❑ J Distance to nearest: Well -Foundation Property Line k SEEPAGE PITS I 1 Depth Size Number i SUMPS L1 Distance to nearest: Well 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 District-- w 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 k 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 ofYCalifornia,_ ,.' 1a The applicant str equi -r ctions. Complete rawing a e arse side. Signed X Title: 4 Date: t FOR DEPARTMENT USE ONLY G Application Accepted by Date r Area v Pit or Grout Inspe by Date. Final Inspection by Date Additions! Comment �� Z V — y14a } ; �❑ Silk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 839-6385 Y' 1 1 G-t6u f Applicant- Return all copies to: Environmental Health Permit/Services-1601 E. Hazelton Ave., P.O: Box 2009, Stk., CA 95201 a Q # FEE NFO 1 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT O• + EH 13-24 4REV.i i n 51 � �v o R - �••- q—� EH 14.25 - --- _ r~/rWl CJ ! ^•