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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR-FROM DATE ISSUED' { (Complete♦in ii;0:C Triplicate) ' s �• ., E .�+ Xi-., i'•tt. 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 R41es and Regulations of the San Joaquin i Local Health District. .tti . � I Job Address ' C' .A LoSize./u PM Owner's Name Address Phone- Contractor Address r�� ® License Noone k TYPE OF WELL/PUMP: NEW WELL; EI WELL REPLACEMENT El `. DESTRUCTION ❑ PUMP'INSTALLATION 0 SYSTEM REPAIR ❑ rt OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK - �—SEWER LINES , DISPOSAL FLD.� PROP. LINE FOUNDAT0 , �!V Fes, AGRICULTURE WELL OTHER WELL PITS/SUMPS i': M AREA CONSTRUCTION SPECIFICATIONS`. INTENDED USE TYPE OF WELL ,PROBLE c`• _ -,, ,; _ f' ' r +i f Well Casin ❑ Industrial ❑ Open Bottom ❑`Montego( Dia,of Well Excavation Dia. o e g ❑ Domestic/Private ❑ Gravel Pack '' ❑ Tracy f j Type`of Casing +1 Specifications Il [3 Public F1 Other a rt] Delta .bepth of~Grout Seal i.; Type of Grout i rll El Irrigation �ApproxflDepth Qd:Ees_fern f., Surf e,5eal Irista tl_ by k � �J✓ Repair Work Done ❑ ' Type of Pump '-tea/4 x H:P St""ate Work Done Well Destruction ❑ WellDiameter�A' _ 'Sealing+Mat�eriah(top 50'') `" Depth ' - ' .,Filler Mate ali($elow '),! - TYPE OF SEPTIC WORK: NEW INSTALLATION* REPAIR/ADD_ ITfON DESTRUCTION, -fNo septic.system permitted if public sewer is t e Y -' i ' if. available within 200 feet.) o Installation will serve: Residence-I— Commercial 11 Other i Number of living units:—I— Number of bedroo s �Lf' __tea_ . w,""' "� 7 I Character of soil to a depth of 3 feet: /�.d — _ Water table depth I SEPTIC TANK Type/Mfg - 1 Ca_pa_city I2=0 C? -_ No. Compartments PKG. TREATMENT PLT. ❑ , 4 I Al Method of Disposal �� f Distance to nearest: Wel. Foundation Property�Line i LEACHING LINE ❑ No. & Length of lines * :✓' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 7 SEEPAGE PITS ❑ Depth ". Size ""' Number SUMPS ElDistance to nearest: Well Foundation Property Line - .i 1 DISPOSAL PONDS ❑ s ' f -I hereby certify that 1 have prepared this application and that the work will be'done in-accordance-with-San-iJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i ' i 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 I employ any person in such manner.as to become subject to workman's compensation laws of California." Contractors 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." i { I The applicant1pust call for requ' inspe io S. Complete'drawing on reverse side. 9 5igrledTitke: Date: t FOR DEPARTMENT USE ONLY Applicatign Accepted by F Date Area Pit or Grout Inspection by .'Date Fi®all Inspection by Date Additional Comments: ❑ 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED.. CK# RECEIVED 9Y DATE PERMIT"NO.' INFO CASH ' I + EH 13-24(REV.r/as) M EH 14-26