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r APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA' Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Ordinanc N p e o. 549 for sewage or No. 1$62 for well/ um and the Rut 4 tY g P P e es and Regulations of the San Joaquin I� Local Health District. II I � Job Address .4 City Cl Lot Size PM Owner's Name "+ Address Phone Contractor Address Y: 1Y %�� License�No. ?Phone TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE�F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑,Manteca Dia. of Well Excavation l Oia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing h Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout. .', I I Irrigation 4 _Approx. Depth `l I Eastern Surface Seal Installed by I _ Repair Work Done ❑ Type of Pump H.P.r state Work Done Well Destruction ❑ Well Diameter----- --Sealing Material (top 501 f l + Depth a Filler&Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION " REPAIR/ADDITION l I DESTRUCTION 1 i INo'septic system permitted if public sewer is W 1 available within 200 feet.) Installation will serve: Residence Commercial ` Other t f Number of living units: 'NumbEtr"of bedrooms`.."_ f ^(1 v 1 Character of soil to a depth of 3 feet: r'•' ! Water table depth SEPTIC TANK ❑ Typ )Mfg Capacity 00 f No. Compartments PKG. TREATMENT PLT. ❑ t fMethod of Disposal f r osal p Distance to nearest: Well - Foundation'" Property �[� .___` Line LEACHING LINE No. & To Len Length of.lines ~ 6 9 � '' �� '�"_ tal length/size FILTER BED ❑ Distance to nearest: Well Foundati`on,��Property Line � 4 t i SEEPAGE PITS i I Depth k i Size Number i I' SUMPS ❑ Distance tornearest: Well Property DISPOSAL PONDS .. ❑ } iJ. 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. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws'of California."i 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 laws of California." The applicant must call for all r uired inspections. Complete drawing on reverse side r` Signed X v � 'Title: r Date: FOR DEPARTMI_NT USE ONLY # Application Accepted by i Date Area t Pit or Grout Inspection by b" ;4` Date Final Inspection by Date L Additions! Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box'2009, Silk., CA 95201 41. s-• ^^"'Cilk •INFO'- ,_,_FEE AMOUNT,.OUE_ —AMOUNT,REAIT.TED.y:.-..,-CASl1."'"..,v,.,,.RECEIVED.BY.,.-�.,- ,,---DATE- .. •-..pIrRMIT�NO.•-• �-�-�� J r+.EH 13-24 f�51. :v_..�..... ........,_._ ...�.�..�r «...�......�.............W�.. .�.. �,�j _.. .,,:...-Y.,, n. EH 14-26