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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ` Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y 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 '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. ; 7 V 4 G Lot Size 4 PM 7 Job Address �� City Owner's Name 9.4 Ee,-(alows Address Phone Ef Contractor .f Address License No. �Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP-INSTALLATION CO "� '-"" "'SY•STEM-REPAIR"❑"——"tr —OTHER-0-'- , DISTANCE..TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , 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 F ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public f7 Otdept her ❑ Delta h of Grout Type of Grout e F 1 Irrigation - _._Approx. Depth I 1 Eastern Surface Seal Installed by— Repair WorO Done ❑ Type of Pump H,P. State Work Done I Well Destruction '�.D Well Diameter Sealing•Material Itch 50') l s Depth Filler Material„f Below 501 1 TYPE OF SEPTIC IA/ORK: NEWINS.TALi{1TIONREPAIR/ADDITION t I DESTRUCTION l 1 (No septic,system permitted if public sewer is �J .. available within 200 feet.) , / sUJ Installation will serve: Residence L/ Commercial Other - Number of living units: I Number of'beci26oms i - Character of soil to a depth of 3 feet: r Water table depth " 'W. SEPTIC TANK i<Y Type/Mfgc7J'1�f a a• Capacity_1 f — No. Compartments i PKG. TREATMENT PLT- ❑ r ) `,.r.•�: Method,of,Disposal Distance to nearest: Well ZIX Foundation 1c? Property Line's LEACHING LINE V'-No: & Length of lines y Total length/size t: FILTER BED ❑ Distance to nearest: Well..-_�� Foundation P'operty Line ^"1 SEEPAGE PITS 1 I Depth 16 Size /o - Number_ ” SUMPS l i' Distance to nearest:' 'I .Well } _ Foundation ,3�� Property Line DISPOSAL PONDS ❑ 4 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.`-`•k a 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."Contrac'tor'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 must call for all squired inspections. Complete drawing on reverse side. Signed X Title: Date. F DEPARTMENT USE ONLY Application Accepted by-- � Area. /� Pit or Grout Inspection by Data ,Final Inspection by "'Date Additional Comments: ❑ 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 # F FEE } AIiMODNVO0E ANi0l7NT REIu11TTEl) YCASHr _RECEIVED BY_.„ DATER( PERMIT"ND. INFO +.EH 13-24(NEV.t/H 5) EH 14-26 ��`�