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WLAPPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. it I r . Job Address C +e;L0 1ZT7 City Lot Size pM I Owner's Name AJ Address 9`40I Phone Contracto Address;3 L L%nse No.;Y__ V 3 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 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 4 . ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,Specifications'— Ll Public ❑ Other ❑ Delta Depth of GrdBt Seal Type of Grout El 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 (top 50'1 �' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITfON ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f " aJailable within 200 feet.) Installation will serve: Residence_/ Commercial_ Other .;Number of living units: Number of bedrooms 'Character of soil to a depth of 3 feet: a^ Water table depth a SEPTIC-TANK Type/Mfg 1: Capacity Q� No. Compartments _Z_ PKG. TREATMENT PLT. ❑ e T Method of Dis oral Distance to nearest: Well' o -'~_ IDbi,Fouyndation ?s� Property Line Oe. LEACHING LINE No. & Leng0of lines �r3 Total length/size_ S _ FILTER BED ❑ Distance to nearest: Wait Foundation Property Line SEEPAGE PITS FT— Depth 7- Size T;111 Number SUMPS ❑ '.Distance to nearest: Well_2 d(j— Foundation l� _ Property Line �� F DISPOSAL PONDS ❑ 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 F tion laws of California." ! The applicant must call forall wired inspect s. mplete drawing on reverse side. i x y }, Signed X Title: Date: p FO TMENT USE ONLY Application Accepted by { r _ Date Area Pit or Grout Inspection by Da Final Inspection by Date Additional Comments: `_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8,23-7104 O Trac 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2909, Silk., CA 95201 r y 9- 7 4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 10- DATE PERMIT"NO. INFO SH + EH53-24[REV, EH 1426 / L"") f} /k�