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APPLICATION FOR PERMIT ? SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL T 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. �� 1�Cir. Job Address . sL+ City GLr Loi Size . PM Owner's Nam Address SLOQa AA /t-Gl Phone J,33 31 Contract _ Address PQ —License No.&&z�tP Phone `BIOS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type e of Casingr Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material flop 50'1 . } a Depth Filler Material IBelow 601 �! TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence Commercial— Other Number of living units: �� Numb�ro�f4�b ,, ursCharacter of soil to a depth of 3 feet: r. rSEPTIC TANK Type/Mf ,;.� Water table depth 'fg -- -Capacity-- -�- iO No�Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well�QFoundation Property Line LEACHING LINE Zr No. & Length of lines -2-" YjQ4 Total length/size d FILTER BED ❑ Distance to nearest: Well 4%!5_ Feundation—/0_ Property Line S, - SEEPAGE PITS l Depth Size 13 ` j Number - a SUMPS ❑ Distance to nearest: Well es Foundation /0 1 Property Line DISPOSAL PONDS D I hereby certify that I have•pfeper'd•ih s..8pplicatiori and that the w'ark uvill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin`Local Health District. :, + t•: Home owner or licensed agent's signature certifies the following: "I certify that-in-the pe`rformance.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-s6b-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 io workman's compensa- tion laws of California." r1 The applicant must call for aQ required inspections. Complete drawing on"r`eve.,��• Signed X -Title: ' Date: FORDEPARTMIENT USE ONLY Application Accepted by� f Date _J Area it o� Grout Inspection b � C Y/_� T Date ~ '� inal 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 ASH RECEIVED BY J` DATE PERMIT'N0. + EH 13-24(REV. EH 14-2e �� •o o / �33 r }