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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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 r Local Health Diis)trict.�] (�1 i 0 Job Address[L!0 ( Q� � _ City Lot Size PM Owner's Nam�L _ Address ! Phone 309U Contract I Address ,•�� License No, z�Z Zip Phone 3�� J' S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El"' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ {ter OTHERr❑.�� -K 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 of Casing Specifications i M Public ❑ Other i=1 Delta s Depth of Grout Seal Type of Grout I l Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wel! Diameter Sealing Material Itop 501 Depth ler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I IREPA /ADOITtON X, DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) o Installation will serve: Resi ence p'Commercial Other Number of living units: Number of rooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK Type/Mfg Capacity _ No. Compartments F PKG. TREATMENT PLT. ❑ Method of Di§posal Distance to nearest: Well 77 .__,;Foundation -_.— Property Line S LEACHING'LME ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth Size _ Number .-SUMPS r Ll Distance to nearest: *Well - Foundation —Property Line t 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 Di§trict. 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 of 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 t call for r uir inspections. Complete drawing on reverse 'de. Signed X Title: Date: r FOR DEPARTMENT USE ONLY Q JU l Application Accepted by Date Area 2,-t 3� r Pit or Grout Inspection by Data Final Inspection by Date `l Additional Comments: El Stk 4664781 ❑ 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 NT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"No. INFOAMOU ��CJJgqASH ` r +.IEH 53-24 IREV,t/H 51 �� uV` �' � y`lS 'Ci 1 1 ^0 lQ EH 1426 111