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"` APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 3 [�� 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 — City _ +5[- d� Lot Size PM Owner's Name b- Address Waa S I (ZKb Phone Contractor___&r_\ \ —Address License No. Phone TYPOF WELL/PUMP: NEW WELL 71WELL REPLACEMENT 1-1 DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: ANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I 13Industrial ortam L1 Manteca Dia. II Excavation Dia. of Well Casing ❑ Domestic/P ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ri Pub ❑ Other Delta Depth of Grout Seal Type of Grout I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ADDITION LI DESTRUCT( I (No septic system permitted if public sewer is # available within 200 feet.) Installation will serve: Residence commercial— Other Number of living units: _W Number of bedrooms—M Character of soil to a depth of 3 feet: . Water table depthM SEPTIC TANK 21"Type/Mfg ' Ca it No. Compartments Q PKG. TREATMENT PLT. ❑ Method of Disposal Distance to ne :mt��y baveeMonnithOu} Property Line � e�— LEACHING LINE No. & Length of ilnes rota) length/size eo FILTER BED ❑ Distance to neareyl N l'np oundation Property Line •i f SEEPAGE PITS I I Depth Size - _^ Number SUMPS Ll Distance to nearest: Well Foundation'. 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 1 rules and regulations of the San Joaquin Local Health District. x 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 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. Complete drawing on reverse side. Signed X .41, � �� `Nen Title: sr� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z Area # Pit or Grout Inspecti n Date Final Inspection by Date Additional Comments: .__ ►" fl I ► / C_r r- �/��t ❑ Stk 466-6781 ❑ Lodi ❑ANanteca 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 RECEIVED BY DATE PERMIT-NO. INFO +.ER 1324(REV.I/H 51 �1� 0�3 t' j }ti 0 d. EH 14-26 li