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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA y Telephone (209) 466-6781 Sf e D't f O 8 SO A4 1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Sif 1Sf 46 — X/6,3 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 �-44/2, City 4 Lot Size pM Owner's Name Addres Phone Contractor's Name IC's-�-SLA ¢ ]�11 License No. TYPE OF WELL/PUMP: NEW WELL ❑ Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack Q Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal F-1IrrigationType of Grout --Approx. Depth ❑ 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 '1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is L Installation will serve: Residence A Commercial available within 200 feet.) Other Number of living units:1_ Number of bejrooms Character of soil to a depth of 3 feet: J� SEPTIC TANK Water table depth7HE ❑ Type/Mfg Capacity - No. Compartments 1- PKG. TREATMENT PLT. F-1i Method of Disposal A Distance to nearest: Well Foundation Property Line i LEACHING LINE No. & Length of lines Q Total length/size V X -A' r FILTER BED ❑ Distance to nearest: elly , .s 0 Foundation__ /� � Property Line I SEEPAGE PITS Depth Z Size XZ SUMPS Number ❑ Distance to nearest: Well� FoundationProperty Line DISPOSAL PONDS d l ,�r 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 m t call for I r quired ' ction Complete drawing on reverse side. Signed Title: — l� Date: 01 FOR DEPAR MENT USE ONLY Application Accepted by Date ` O— J— © r d_ Y4 Area rt Grout inspection bye Date Final Inspection by Date�� nal Comments: tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63% App ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO 1 1 CASH RECEIVED BY DATE PERMIT`NO. + EH 1}24(REV. 10/831 u� ,2,,� EH 1428 �