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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON 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 i 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- e— +� t Cit Lot Size PM Job Address f y Owner's Name dress Phone Contractor `, {[..� Address CLicense No. —f - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUl.7URE WELL_ OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom " ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing 91) T e of Casin Specifications [I Domestic/Private ❑ Gravel Pack "❑ Tracy YP 9 ' 1 F Type of Grout ❑ Public ❑'Other :❑ Delta Depth of Grout"Seali, ; Yp f Jr t " � I Irrigation Approxi Depth `I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Dane 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth i t Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION TRUCTION [ I (No septic system permitted if public sewer is I AT� available within 200 feet.) Installation will serve:' Res'deri a_Commercial Other Number of living units: , Number of bedrooms, Character of soil to a depth of 3'feetI_.�hT'\ 7�� Water table depth Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg s r PKG. TREATMENT PLT. ❑ x1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE f �& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ._ , j. SEEPAGE PITS F I Depth ' Size Number ] SUMPS Lr kianceFito nearest: Well Foun ation 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 I s, 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 a f California _� I' !! The applica t call for req 'ed in ction to drawing on r verse side O f Signe Title: Date: i FOR DEPARTMENT.USE ONLY. A. ' +� Ial { Date Application Accepted by ~ �— r Area Pit or Grout Inspection b t y �' : Date Final Inspection by_ Date Additional Comments: ❑ Silk 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, Stk., CA 95201 I FEE OUNT DUE t AMOUNT REMITTEDTCASH RECEIVED BY DATE PERMIT NO. INFO / / y �3�J - ♦ EH 13.24(REV.I I H 5) -7f7• � c7 F ��0 �/ 47/7— " EH 14-28 !f--