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i ` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone f209) 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. /1 9 City Lot Size �� !!� Job Address (� Owner's Name Address Phone Contractor ss a No- 01 Phone TYPE OF WEL(IPUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 EJ Industrial ❑ Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ° t Cl Other D Delta Depth of Grout Seal Type of Grout _- s I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Wofk'.Done D Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 50') — Depth Filler Material IBelow 50'1 F TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_L Commercial_ Other Number of living units__J_ Number of bedrooms Character of soil to a depth of 3 feet:• - - -X pt? 1Water table depth SEPTIC TANK ° ❑ Type/Mfg Capacity , No. Compartments f PKG. TREATMENT PLT. ❑ k ° Method °/� sosal M ` Distance to nearest: Well Foundation Property Line / (J I ifj LEACHING LINE ❑ No. & Length of lines l Total length/size II FILTER BED ❑ Distance to nearest: Well /10,0 7"'k Foundation Property Line — Fr SEEPAGE PITS l I Depth 0 ' Size i Number t- + SUMP Ll Distance to nearest: Well IRK_ Foundation - Property Line 6 O DISPOSAL PONDS ❑ ti 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 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 applican ust II f all re Ire inspections. Complete drawing on rpyerse side. l Signed': Title: Date FOR DEPARTMENT USE ONLY _ ' Applicatio/n,Accepted by �_!.Y f 1-c-- c Date Id Area of 6;/4- z 1Date�� Final Inspection by Date r o Inspection by l 70 r7l Additional Comments: If ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D 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 PERMIT'N4 O. WFO ��''""�� 324 + EH 14.24IREV.'1n51 .. /( ].