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f f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ! � 1601 E. HAZE.TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 A;,k4 District. .r-Job Address Jw"O.�QCity Lot Size PM Owner's Name Addresst � r [.�ilIkC' Phone ff r Contract Address License No SD 2 77 - Phone { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �.4 PUMP fNSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -FOUNDATION-.___. __ _AGRICULTURE WELL— _OTHER WELL _P_I-T-S/SUMPS-„=_ 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom If Manteca Dia. of Wel! Excavation Dia. of Well Casing y EJDomestic/Private -..❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q f Public ❑ Other l -Delta Depth of Grout Seal Type of Grout !q - k ! f I I Irrigation Appro pepth I ] Eastern `_ Surface Seal installed by IlJ[//.till `k Repair Work Done ❑ Typel.of Pump H.P. - State Work pone I Well Destruction ❑ Well Diameter Sealing Material:itop 50 /_t{ Depth' Filler Materia (Below 50'1 I TYPE OF SEPTIC WORK; NEW INSTALLATIO REPAIR ADDITIO K DESTRUCTION I, I (No septic system permitted if public sewer is available within 200#eet.i Installation will serve: Residence SCommercial Other 4 Number of living units: Number bedraoms�,A 'Y� s. Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg t Capacity/ Od_ No. Compartments PKG. TREATMENT PLT. ❑ l; Method of Disposal Distance to nearest: Well_ice„- Foundation Property Line A_, LEACHING LINE No. & Length of lines V _ Total length/size d X t FILTER BED ❑>`` Distance to nearest: Well`�]0,1 Foundation � property Line ;r/ ! t t SEEPAGE PITSI. Depth s:- Size _ - Number SUMPS Cl Distance to nearest: Well t� Foundation..._ r 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 District. s,_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 s employ any persori.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 st call for rre� 'ed in`s q pechons. Complete drawing on reverse side Signed Title: Y" f`+ ` ,' FOR DEPARTMENT USE ONLY t �.z�- Application Accepted by ^� Data Area _ s E Ior Grout Inspection by pate ! Final Inspection bypp- ,Date Additional Comments: ' 1 E ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Se rvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t _ , ff$O CK UNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT NO. ♦.EH 13-241REV.fix 5)Eli114.26 - -4 l 0� �•�-ice, - "Q`L� i�V � M