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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address,33 l l C? of l d f ` .. n r to ru.. .. City -1-[d- LrLot Size PM - r Owner's Name Address- - _ - - Phone . � ��'` r Contractor C'rRc ddress `a License No.4A 5'VV Z Phone d TYPE OF WELL/PUMP: NEW WELL E1 WELL REPLACEMENT ❑ DESTRUCTION EJ PUMP INSTALLATION �, SYSTEM REPAIR ❑ OTHER ❑ C 1, 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 ExcavationO Dia- of Well Casing X.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern `Surface Seal Installed by ; Repair Work Done ❑ Type of Pump H.P. / State Work Done Well Destruction LIWell Diameter Sealing Material 66p 50'I Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJDESTRUCTION Q (No septic system permitted if public sewer is )'"",ivaillablewithin 200 feet.) I Inson will serve: Residence— Commercial04 _ Other Number of living it Number of bedroomsc/ I Character of soil to a depth of 3 feet: ' 14Water table depth SEPTIC TANK ❑ Type/MfgJf - `Capacity- - No. Compartments PKG. TREATMENT PLT. ElI Method of Disposal Distance to nearest: Well I Foundation � rty Line LEACHING LINE EI` No. & Length of lines ^ Y l I Total length/size FILTER BED' ❑ Distance-to.nearest:-•-r-Well Foundation 1. ;Property Line SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ Distance to nearest: Well.. - Foundation Property Line- DISPOSAL PONDS El t 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, a rules and regulations of the San Joaquin Local Health District. -4 nd I: 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•Califomia:"•Contractor's•hiring-or•sub-contracting signature certifies the following: "I certify that-imthe'Wrformanc" a 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 required inspections. Co mp1te-drawing on reverse side: Signed t Title: .. �. J Date: FOR,DEPAR ENTUS Y Application Accepted by Date` Area Pit or Grout Inspection by Date ; 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY' DAT/E + {REVt i a 51 �....� PERMIT'NO. ` EH 1426 , - � r t- V �sF / ��yrl