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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. I/ Job Address CLV) ` City Lot SizJ05 )("145 PM -a ��c Owner's Name Address • Cr '�`" ^ " Phone ' ,2gZZG Phone Contract Address Address .� � License No., TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open-Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public Cl Other -T_1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth s l-I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is F= available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: / Number of Character of soil to a depth of 3 feet: r oms Water table depth SEPTIC TANK 1r Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r /` - - / Method of Disposal Distance to nearest: Well Foundation_/47 Property Line txs�- ' f LEACHING LINE Li• Na. & Length of Eines 4 L4 0 Tytal length/size FILTER BED E] re Distance to nearest: Well r QO z Foundation Property Line .- 7�`� SEEPAGE PITS Ia�Depth _Size Number SUMPS Ll Distance to nearest: Well!�0 Foundation F n.. Property Line _-.�..._.._ DISPOSAL PONDS ❑ 3 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 applicant st call for all uired inspections. Complete drawing on reverse si M �, Signed X Title: �� Date: S 1� 1 k"tt 27 FOR DEPARTMENT USE ONLY � �7 Application Accepted by Date�/ f Area / 2— Pit 'r Grout Inspection by ate Final Inspection by „/ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH JJ r EH 13-24 IREV.t i H 5) ?-Zo / V 7� EH f4-2a