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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Local Health District. m 1$62 for welllpup and the Rules and Regulations of the San Joaquin Job Address E City Lot Size �— ply f Owner's Name Address Phone r Contractor % �-� Addressd �7 License No. SfQ Phone TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION DISPOSAL FLD. PROP. LINE AGRICULTURElWELL OTHER WELL PITS/SUMPS INTENDED USE TYP.E OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Indusfnai_ z ❑ Open Bottom ❑ Manteca . Dia: of Well Excavation Dia. of Well Casing ❑ Domestic/Pfivate ❑ Gravel Pack © Tracy Type of Casing Specifications I I Public.%::'r F. Other 1.1 Delta f `7 I Depth of Grout Seal Type of Grout I I irrigation, ; ,fir ',, ".-Approx. Depth I I Eastern Surface Seal Installed by a. fl pair Work Done ❑ Type of Pump H.f r State Work Done 4Well Destruction 13 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION,IJ-(No septic system permitted it public sewer is 2� , / .1 available within 200 feet.) , Installation will serve: Residence A Commercial — } her' r~ ' • "� - -� ^-- ;`� ,r Number of living units: �L— Number of bedrooms t ~: Chdracter4of soil toy 1a depth of 3 feed Water table depth � SEPTIC :TANK' - • �1 O TYPe/JNfg; � i r�Capacity.% No. Compartments PKG. TREATMENT PLT. Cl ; r r:4x ♦ Method of.,Disposa Distance to nearest: Well! t FtoundaiIon v - Propercy Line LEACHING LINES No. &Length of lines } ,/ . �. FILTER BED ❑ Distance to nearest: Well /00-1, Fou SEEPAGE PITS I I Depthfi Size SUMPS Distance o nearest: Well (— DISPOSAL PONDS ❑ r Total length/size idati.�n'LaProperty Number Foundation i -?X>'� rot P y � r` Linef7 IN 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 41, "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following 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,-( shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all re (red inspections. Complete drawingran reverse side f. Signed X I Title: f — Date: FOR DEPARTMENT USE ONLY r �~ r Application Accepted by a Date Area ' f Pit or Grout Inspection by Da �L Final Inspection by Oa �/ R< Additional Comments: j LJ OtK , w%W-o/U i u 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 - 1 FEE AMOUNT DUE AMOUNT REMITTED CK (NFO -CASH e... RECEIVED BY -4- _ DATE _. - .... PERMIT�I +.EH 1-24 {REV. tix5] EH 144-28 ()/ —� �. s r � �..'t` v(f 4