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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 1 - A 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ and the Roes and Regulations of hire p^a �on is Local Health District: Joaquin Job Address Cityo44LZYAeLot Size PM i Owner's Name r - Address D � Tim one ff Contractor �' � -�>� Address �R �� Jd" i TYPE OF WELL/PUMP: License No.�phone NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION CJ tt PUMP INSTALLATION ❑ ` ` "` — SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST;/SEPTIC TANK SEWER LINES i DISPOSAL FLD. PROP. LINE + J° j =t,. FOUNDATION AGRICULTURE WELL € OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial w ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private I O Gravel Pack ❑ Trac Dia. Of Well Casing • Public 'µr E tom; �-°. y Type of Casing Specifications ❑ Other r J Delta ❑ Irrigation ' s l Depth of Grout Seal Type of Grout —,Approxi Depth �°Eastern Surface Seal Installed by b Repair Work Done ❑ Type of Pump H p Well Destruction ❑ Well Diameter State Work Done Sealing Material atop 50'1 Depth ---w..yFiller-Material {Below 50'1 1 TYPE OF SEPTIC WORK: NEW INSTALLATION Q t EPAIR/ADDITI,ON ❑ DESTRUCTION (No septic system permitted-rf public t sewer is Installation willResidence available within 200 feet.) serve; Commercial, Other Number of living units: Number of bedrooms ! Character of soil to a depth of 3 feet ,, j i ! ` """' �".Water-table`depth SEPTIC TANK 1 ❑ T-Type/Mfg e PKG. TREATMENT PLT. ❑ - YP 9 Capacity No. Compartments I Method of Disposal 1 /� Distance.to nearest: Well i Foundation I Property Line. v ` LEACHING LINE ❑ i \ No. & Length of lined i FILTER BED Total length/size ❑ Distance to nearest: f� Well Foundation Property Line r SEEPAGE PITS ❑ Depth i Size 1 SUMPS - Number ❑ Dist1 Distance nearest: Well F Foundation t DISPOSAL PONDS ❑ i Property Line s �- I hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin county ordinances, L rules and.regulations of the San Joaquin Local Health-District""""""!"' inances, state laws, and 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 tion laws of California.,, 11 permit is issued,I shall employ persons subject to workman's compensa call for ll re / The applicant must aed i ctions. Complete drawing on reverse side. S Signed Title' Date: L7` OR NTt USE ONLY -� Application Accepted by I Z C } Date Area Pit or Grout Inspection by Date Final In y Inspection b Date S Additional Commehts: ex—rn,AS ; ❑ Stk 466-6781 ❑ Lod i 369 3821 ❑ Manteca 823-7104 Ll Tracy '835-6385 Applicant- Returniall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 MOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY. DATEQ�] P(EERMIT'^N�O, + EH 14-28 IREV. /B51 �