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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT # 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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. / Job Address 1Z / oD 04.44� pG City Lot Size PM Owner's Name ¢ V Address a `l Phone Contractor Address 16—A ?to 2 1• .ei ..-License No.3Z8 '77! Phone TYPE OF WELL/PUMP: U NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REP ff L] OTHER .❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM�ARCONSTRUCTION SPECIFICATIONSC1Industrial ❑ Open Bottom C3MantDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L1 cy Type of Casing Specifications 1'1 Public 17 Othe�Ump _ f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.-A 1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Typ H.P. StateWork Done \ Well Destruction ❑ ell Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 — TYPE OF SEPITC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) ^ I In will serve: 'Residence's Commercial_ Other \`\3 Number of living units: Number of edrooms Character of soil to a depth of 3 feet: Water table depth 7 SEPTIC TANK Lrr/Type/Mfg -_. �- -�'� Capacity /to V& No. Compartments 1, PKG. TREATMENT PLT. ❑ ! J Method of Disposal Distance to neatest: Well Foundation Property Line LEACHING LINE Ur No. & Length of lines 3 q o t Total length/size FILTER BED ❑ Distance to nearest: Well tt Foundation_ /D Property Line S SEEPAGE PITS lPe-Depth Size v ..�__,.� Number SUMPS Ll Distance to nearest: Foundation�_. Property Line DISPOSAL PONDS ❑ i 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 i rules and regulations of the San Joaquin Local Health Diltrict. 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." Contractor's firing or sub-contracting signature I 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 mu all for all required 'nspections. Complete drawing on reverse side. C� Signed X Title: Date: I O r 17 o FOR DEPART ENT USE ONLY 9 Application Accepted by Date G `r Area r / or Grout Inspection by Data 12- Final Inspection by ate[ 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, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT'NO. I INFO CASH +.Eli13-24(REV.I/n5) ,�; D k EH 14-261 N f 9 .,