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e t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AV1601 E. HAZE i ON 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. J U jj,t l�/ar+fP r /�'W►�1ir ? �� "�f1 f)` Job Address / � `�' ~i'v� ` CitLot Size PM i s Owner's Nam � Address Ph ne Contract : r Address P.o� cx`l o[ Q&License N0 � �� D61 Phone. p• TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications , 1'1 Public L1 OtherA ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --,Approx. Depth..;. l I Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump = '' 1 H.P. State Work Done _ f Well Destruction ❑ Well Diameter —Sea ling-Material-ftop-50.1 .,f Filler Material (Below 501 TYPE OF SEPTIC WORK: -NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I k 1No septic system permitted if public sewer is _ \1 -1-11 available within 200 feet.) N. Installation will serve: ResidenceCommercialCommercial_ Others' Number of living units: I Number o droe ' Q a. y� Character of sotl to a depth of 3 feet: Water table depth SEPTIC TANK Ut"Type/Mfg \ CapacitV." 266 4A1 No. Compartments PKG. TREATMENT PLT. ❑ :: ? �`�- Method of Disposal ti Distance to nearest: Well Foundation © f -_Property Line i l � LEACHING LINE P�' No. & Length of lines ® u^ Total length size C' X FILTER BED L) Distance to nearest: Well--� Foundations ® Property Line, SEEPAGE PITS I►-�Depth a Size �7 "q "`fit="eiVumber i SUMPS ❑ Distance to nearest: Well Foundation - L - — Property Line DISPOSAL PONDS ❑ r•. " 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. ! . 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;co`rnpensation laws of California."Contractor's hiriri'g or sub-contracting signature <. certifies the following: "I certify that in the performance of the work for,which-th'is,.permit•is`issued, I shall employ persons subiect' to workman's compensa- tion r _ .. 1 tion laws of California." � The applicant st call for all fired inspections. Complete drawing on reverse side. Signed X Title: Date: L if ( FOR DEPARTMENT USE ONLY r i Application Accepted by __ .__ Date ec, 1 Area Pit or Grout Inspection by Data Final.Inspection by r "�"r Da`ta AdditionaComments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 9952015,4 F72i3 i IFEE I NFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT"NO. i . EH 13-24{REV.1 i n sl EH 14-2e k