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A d_ p APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 N PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) p 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. f e Job Address/ / !�/a "ll.I�9�J1 v �: Cit 10 r V Lot Size PM ! Owner's Name Address Phone rr / Contractor a'�Address r • License Nd. z _F'hon TYPE OF WELL/PUMP: NEW WELL �❑ 'WEL 'REPLACEMENT ❑ DESTRUCTION E PUMP INSTALLATION f SYSTEM REPAIR ❑ OTHER El 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 AR dustrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C-Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications � F] Public 171 Other I F Delta Depth of Grout Seal Type of Grout_ _ ! I I Irrigation _..Approx. Depth Eastern rf uace Seal Installed by Repair Work Done Type of Pump H.P� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet:) Installation will server Residence_ -Commercial T Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water`ta61e depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property_Liner LEACHING LINE ❑ No. & Length-cif lines Total length/size FILTER BED ❑ Distance to nearest-.'- Well Foundation Property Line w SEEPAGE PITS I I Depth I Size Number SUMPS Cl Distance to nearest: WellFoundation Property Line I 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 Dilarict. 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." t �. The applicant m r all requireO'irl pectin Complete drawing on reverse side. r -' Signed X Title: Date: `i�%' ` y / FOR DEPARTMENT USE ONLY � 2W ' Application Accepted by �L/ Date Area Pit or Grout Inspection by Date Final Inspection by Dates ld Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362it ❑ 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 f FEE l INFO AMOUNT DUE ' AMOUN7 REMITTED --GASH RECEIVED LiY DATE PERMIT"NO. I, ♦.EH13-24(REV.1 i e 5) y .EH N-28 Cain F