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APPLICATION FOR PERMIT D SAN JOAQUIN LOCAL HEALTH DISTRICT /y 1601 E. HAZELTON AVE., STOCKTON, CA � Q 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 0 Cit Lot SizePM Owner's Name f d""e, Address�a Phone Contractor �J ' r,Id Address icense NoPhone TYPE OF WELL/PUM : w NEW WELL O - ,;' WELL. REPLA�EM DESTRUCTION ❑PUMP INSTALLATION ❑ SYSTEM OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I f FOUNDATION AGRICU E WELL OTHER WELL PITS/SUMPS, _ INTENDED USE TYPE OF WELL PROBLE REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public F I Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation pprox. Depth 1.1 Eastern Surface Seal Installed by _ Repair Work Done L7 ype of Pump H.P. State Work Done_ Well Destruction Well Diameter Sealing Material (top 56'1 O Depth # Filler Material (Below 501 TYPE CrF SEPTIC WORK: NEW INSTALLATION fEPAI /ADDITION t I DESTRUCTION l I (No septic system permitted if public sewer is available wit,l�in,300 feet.1 Installation will serve: Residence Commercial Other� � � Number of living units: Number of bedrooms�� Ci�1d Character of soil to a depth of 3 feet: SQ o2�1. �Gt� c. W tabEe depthIV - h SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (1 PKG. TREATMENT PLT. ❑ Method of Disposal i I Distance to nearest: Well `/Foundation Property Line �W LEACHING LINE I No. & Length of lines 1 '' W L/I ---_Total.length/.size Z FILTER BED ❑ Distance to nearest: Well Foundation Property Line S�� SEEPAGE PITS Ik"-Depth Qq 5 d�L Size �Y LI Numbers= - SUMPS C Distance to nearest: Well y 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 rules and regulations of the San Joaquin Local Health Di'strict.. ! I Home owner or licensed agent's signature certifies the followi6g: "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 t call for all rea inspections. Complete drawing on reverse side. ' Signed Title: - T� Date: -4 f FOR DEPARTMENT USE ONLY Application Accepted by r '"'°""Datr3 �- ��7 "Area or Grout inspection by /r �m,u ate ,Final Inspection by� it Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permif/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.I/R5) -70 EH 14-W