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APPLICATION FOR PERMIT \ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is he+eby 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. � 0►- 1of Size V f P Job Address' `-" Cit Address Phone Owner's Nar�a� s. Contractor Tess nse lyo f hon ` TYPE OF WELL/PU PP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTR TION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD. --- PROP. LINE- - ---- FOUNDATION AGRICULTURE WELL OTHER WELL ' ^ PITSISUMPS; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificaf'ions [`I Public 1-1 Other Cl DeltaDepth of Grout Sea] Type of Grout -. I Irrigation - _-.—Approx. Depth 1 1 Eastern 'l = Surface Seal installed by y - Repair Work Done} ❑ Type of Pump H.P - State Work Done x Well Destruction ❑ Well Diameter ealing Material Itop 501 - Depth Filler erial (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 10' REPAIR DDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 fact.) 4 j Installation will serve: Residence— Commercial Other 4 Number of;living units: Number of bedrooms ra 1 Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg f Capacif d No. Compartments PKG. TREATMENT PLT. ❑ `i Method of Disposal Distance to nearest: Well/ Foundation Property Line i LEACHING LINE , ❑ , No. & Length'of lines `2Y 44e9 Total length/size FILTER BED Distance to nearest: Weld ~Foundation Property Line ____ SEEPAGE PITS 11 Depth Size _ Number SUMPS 0 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 DiMrict. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner its 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 California." The applicant u cal r a ired inspecti s. mplete drawing on reverse side. Signed X I- Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ` Nk A-..1 Date Area Q Pit or Grout Inspection by Date Final Inspection by Ic- ' ! Date / Additional Comments: 0 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 84-63B5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, INFO CASH ♦.EH13.24(REV. —70 C. r3)s�lc I 34 I EH 14.29