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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELT,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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. i!5-per A. Job Address x Al City /V Lot Size c- PM j Address. hone ' Owner's Name � _ ... :�.: p .,:.w..� �.. �. -.�.�. .._•�.--. o cense No.�� x 851 cerise �! Contractor Address Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 101 DESTRUCTION L1 d " \ y OTHER ElPUMP INSTALLATION F] SYSTEM REPAID 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ---------,-.,DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL __ OTHER,,WF-LL .:1 5/SUMPS INTENDED USE TYPE OF WELLPROBLEM AREA 66NSTRUCTIONSPECIFICATIONS_ �. r El Industrial ❑ Open Bottom If nt Maeca Dia. of Well Excavations '"' i Dia. of Well casing El Pack ❑ Tracy .' �, Type of Casing ~" Specifications T ❑ Domestic/Private +*:�,. r "' � r � `• 'T# e of Grout LlPublic Ll Other ; ❑ Delta L Depth of Grout SOal YP d [ ❑ Irrigation ---Approx. Depths Ll Eastern Surface Seal Insta ted by ❑ Type of Pump if S l H. `� I State 1Nork.Done II Repair Work Done . 5 i Well Destruction ❑ Well Diameter Sealing Material atop 501 5 !1 Depth -- -.-,,—.Filler Material elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRLTIO ❑ (No septic system permitted if public sewer is 200 feet.) available within _ `.. t I r Installation will serve: Residence Commercial_ Other Number of living units: Number of bedro ms ti 1 Character of soil to a depth of 3 feet: l i Water tattle depth s E *,-No Com artments''= � � ' r SEPTIC TANK ElType/Mfg t Capacity 4ti P PKG. TREATMENT:PLT. ❑ Method of Disposal A, Distance to nearest: Well $ Foundation Pri perty,Line' ..�. „,.�. • t F LEACHING LINE it No'&` Length'of lines rt Toll lengthzsize t f FILTER BED ❑ Distance to nearest: Well Foundation. Property Line SEEPAGE PITS ❑ Depth- Size ` r�uytber' I SUMPS Distance to nearest: Well6_ =Foundatio Property Liner DISPOSAL PONDS ❑ .t." ; E" I hereby certify that I have prepared this application and that the work will be done iri'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 j 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 i i # tion laws of California." ~f'. i I; The applicant must II r all required i pections. Complete drawingon re erse said y Signed X Title: Date: ~� FOR DEPARTMENT USE ONLY O / Area 196 j Application Accepted by Date r Pit or Grout Inspection by / — Date Final Inspection by *Date Additional Comments: I ❑ 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, Silk., CA 95201 k CK RMIT�N0. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE INFO + EH 13-24(REV.t/H 5l # 0_!'�� �Q'^'� EH 14-28