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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 31..E 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' / t',,/ PM Job Address O City Lot Size—7 yyyy ac - Owner's Name kLg_Ith,, Address - � Phone _-Zn Contractor Addres /' 4- `/ License No � _Phone3 7 { TYPE OF WELL/PUMP: VW7 WELL X WELL REPLACEMENT>< DESTRUCTION ❑ PUMP.'I"NSTALLATION ❑� SYSTEM REPAIR ❑ OTHER❑ DISTANCE TO NEAREST: SEPTIC TANK'_ � ' SEWER LINES" DISPOSAL FLD. 0- Iff-)_- PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL/ / PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI (VS r ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public 1 �HOtl2er 171 Delta Depth of Grout Seal Type of rout(—' eftI } Irrigation' 1 ,}�..Approx. Depth I 1 Eastern JS rface Seal Installed by - Repair Work Done ❑ Type of Pump [2 -..-. H.P. State Work Donej Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC'WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is r Q available within 200 feet.l_ y I Installation will serve: Residence Commercial_ Other. , _�:.- 4Numb&of living units� :�..-.� Nurrlbe�of bedrooms y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal, f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED `r ❑ Distance to nearest: Well Foundation Property Line ' y `s' SEEPAGE PITS l 1 Depth,' Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line r' 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, andhh rules and regulations of the San Joaquin Local Health District. Home owner'or licensed agent's signafure 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."Contractors hiring or sub-contracting signature certifies the.foll.6wing: "I certify that in.the perfof mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion c tion laws of California." r - Tt4 applicant m t call for all re ired inspections. Complete drawing on reverse sid . Signed X Title: ee-_ e f. - Date: i s r FOR DEPARTMENT USE ONLY _ Application Accepted by Date � � * Area Cr Ins C) Pit or Grout Inspection by J Date�"/" -Y Final pection by Date Additional Comments r//� /_� ,tom . ❑ 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 RECEIVED BY DATE N, PERMIT'NO. INFO CASH +.EH13-244-26[REV,t i w sl -.-. _ - - ... _ � _ 'd•'Z..L{ ...�...r�. ,' ` i EH 1S` n a