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i P00 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i I N (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 scribed. This afilplication 9s 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 Joa in Local Health District. i Job Address z-ZOIL City Lot Size C.. PM Owner's NameAddress f 1s. p� f fie,!! `� `.► _-- Phone 838 7`�47 b Contractor's Name —f -^* Licen a.No.- - L �-- Phone ` TYPE OF WELL/P�F?MP: i� NEW WELL ❑ %WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ e SYSTEM IRR ❑'� „ EM REPAOTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL'S PITS/SUMPS — INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION_SP CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing El Domestic/Private C1av G'rel Pack FD Tracy ; Type of Casing ' Specifications %_' I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout k El Irrigation IIA I pprox. Depth ❑ 0Eastern Surface Seal Installed by _r Repair Work Done El Typo of Pump, H.P. State Work Done ;Well Destruction ❑ WeII!�Diameter Sealing Material (top 50') d� DepthFiller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION , REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 11 available within 200 feet.) ' Installation will serve: Residlnce 1,"/ Commercial— Other ~' Number of living units: II Number cit bedroo s>- Character of soil to aepth of 3 feet: Water table depth SEPTIC TANK /f Type/Mfg Capacity, G No. Compartments Z fi PKG. TREATMENT PLT. ❑ ` r Method of Disposal r Distance to nearest: Well Foundation Property Line ' LEACHING LINE No. & Length of lines x x Total length/size 1`�,n y FILTER BED ❑ Distance to nearest: Well ' �__ rFoundation �� Property Line SEEPAGE PITS Depth Z'6 Size a Num�er SUMPS ElDistance to nearest: Well Foundation_.�0 tZ� Property Line DISPOSAL PONDS ❑ 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. 6 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:11 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." II r The applicant must call for all rel fired inspections. Complete drawing on reverse side. oe Signed Title: Date: _4= I� FOR DEP RTMENT USE ONLY rA plication Accepted by !k v ` Date d �LfArea 0 /V Pit Grout Ins I� �1F3t Inspection by [ c .s1...� Date Final Inspection by plea 31 B i krtional Comments: s tk466-6761 0 Lodi f369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 :Applicant- Return all copies to:IfEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MQUNTII DU E AMOUNT REMITTED CK*INFO RECEIVED BY DATE PERMIT`NO. CASH 4 �-• + EH 14-291REV.10/931 ,lyi _ lI- eS �i ..E. �f/ u