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`1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Fes, 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Rt P PERMIT EXPIRES•'I•YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hateby 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 © Cit izo�Lot Size 7 PM Owner's Name Address Phone L> / 1�19-Ait- '—V- ' ' Contractor Address License No, . Phone TYPE OF WE LIP MP: NEW WELL O WELL REPLACEMENT ❑ . DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWAR LINES DISPOSAL FLD. PROP. LINE FOUNDATION .f -AG'RIC'ULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ K4anteca D'ia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack L1 Tracy -.�.Type of Casing Specifications Q 1-i Public 71 Other ❑ Delta, r�: Depth"of Grout Sea] Type of Grout , ' — ! ( Irrigation ---Approx. Depth 1,1 Eastern ,,' I Surface Seal Installed by Repair Work Done ❑ Type of Pump H.'P. + State Work.Done. Well Destruction ❑ Well Diameter Sealing Material Itop 501 1 f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION lir REPAIR/ADDITION L) DESTRUCTION l I (No septic system permitted if public sewer is # available within 200 feet.) Installation will serve: Residence-._ Commercial Other Number of living units: —I— Number of bedrooms Character of soil to a depth of 3 feet:_ - --- --- ------ # '� Water table depth } 'SEPTIC TANK Q Type/Mfg # * Capacity No. Compartments v PKG. TREATMENT PLT. ❑ �' Method of Disp al ' Distance to nearest; Well t/ Foun ation Property Line LEACHING LINE :❑ --No. & Length of lines 4 Total`length/size +� FILTER BED ❑ Distance to nearest: Well./o _Foundation �1dProperty Line_�8 EEPAG E PIT I-1 Depth Size Number UMPS ❑ Distance to nearest: Well 7� Foundation }) ---��J��/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. 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 California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance'of the avoir for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must calf for all re it inspections. mplete drawing on verse side. Signed X Title: ✓s Date: L FOR DEPARTMENT USE ONLY Application Accepted by Date �'� Area f� Pit or Grout Inspection by Date Final Inspection by Date OV , Additional Comments: ❑ Stk 466-6781 0 Lodi 369.3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 f t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT N0. INFO CAST I + EH 13-21(REV:1i851 i9 EH 14-26' - T I