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APPLICATION FOR PERMIT w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. t Job AddressCity Lot Size PM gff7i_-e Address Phone Owner's Name =�- 4tJ ) f� � License No.30t-7� Phone Contract + I Address 1�rl° � `�T l TYPE OF WELL/PUMP-51NEW WELL LJWELL REPLACEMENT 11DESTRUCTION ❑ ; i PUMP INSTALLATION LlSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS vvv ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications! FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout —. I i Irrigation --Approx. Depth l l Eastern Surface Seal Installed by ` Repair Work Dane ❑' Type of Pump H.P, State Work Done Well Destruction El Weil Diameter Sealing Material flop 50'1 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is ,,� available within 200 feet.) Installation will serve: Residence_ Commercial_h-Other; i ` Number of living units: I NumberadrooWater table depth Character of soil to a depth of 3 feet: SEPTIC TANK L� Type/Mfg Co)A] Q- t Capacity n 4 No. Compartments 2 PKG. TOEATMENT PLT. ❑ L E Method of Disposal Distance to nearest: Well�/.._(F,oun dation « i Property Line LEACHING LINE ! �7-K No. & Length of lines O Total length/size ` FILTER BED f ❑ Distance to nearest: Weil Of Foundation—_ Property Li .a a SEEPAGE PITS ; Itt- Depth S Size Number SUMPS •=L�- Distance-to-nearest:—We11-1�=foundation—��PropertiFUne DISPOSAL PONDS 1 ❑ i r 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 Joaquiri LocalHealth Di§trict. Home owner or licensed age is 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.Znner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that inithe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California.' ./ —----------�- -^� --. The applica ust call:for 11 re fired inspections. Complete drawing on reverse side. Signed X i Title: Date: FOR DEPARTMENT U E�O LY��4 Application Accepted by Date ` Area it Grout lnspectioniby ate Final Inspection-b l ` tiJ Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-362F� Cl Manteca 823-7104 El 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 REMITTEDCK RECEIVED BY. DATE PERMIT'NO. INFO w, CASH. y, - " 1 190 +.EH13-24(REV. i e 51 , - EH 14-2a 9 67