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ct�ny . APPLICATION FOR PERMIT G�t� `YlL1' IU[a�t� ortt--d SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Local Health District. f !` Job Address City ;T,t Lot Size T " + PM z i Owner's Nameddress i, Phone+ + f"" Contractor �= " Address License No.--f-- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ jDESTRUCTIO l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ – OTHER ❑ • DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF)CATIONS / ❑ Industrial CJ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casingf -i_ 17 L-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done D Type of Pump,I H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION I (No septic system permitled it public sewer is available within 200 feet.) Installation will serve: Residence—I Commercial` Other Number of living units: Numbellllll(of bedrooms Uri i Water Character of soil to a depth of 3 feet; I `� ter table depth '`t SEPTIC TANK ❑ Type/Mfg f Capacity WaNo. Compartments PKC, TREATMENT PLT. ❑ 3C Method of Disposal Distance toFnesireA Wept,,_ Foundation Property Line LEACHING LINE ❑ No:'glengih of linesTotal length/size X FILTER BED O'YDistance toInearest: Well `,�ndation Property Line y,_ SEEPAGE PITS I I Depth Size �' � Number (,(� SUMPS ❑ Distance tornearest: Well Foundatioh. Property Line DISPOSAL PONDS ❑ .f- } 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 Driltrict. 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. f Signed X ..,n.. Title: + .x _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date .. <� i• L7 Area -� Pit or Grout Inspection by - 'k Dat Final Inspection by Date Additional Comments: t ❑ Sik 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK, RECEIVED!Ely ASHDATE PERMIT NO. . y . EH 13.2 fHEV.1 , �s -- V �� .