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, .I • APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT k 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. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.Q (] f Job Address V i + 5Ot�jH LA N b Pd. City �r Lot Size U `' PM S� Z Phone Owner's Name Contractor l Address License No. . Phone TYPE OF WELL/PUMP: NEW WELL 171WELL REPLACEMENT L3DESTRUCTION 1-1 PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 . ❑ Industrial IJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack LITracy Type of Casing Specifications I`I Public Cl Other D Delta Depth of Grout Seal Type of Grout — (l Irrigation _-.Approx. Depth I 1 Eastern Surface Seal Installed by w Repair Work Done ❑ Type of Pump H.P. State Work D'one Well Destruction ❑ Weil Diameter Sealing Material (top 50') j� Depth Filler Material (Below 50'f — VV TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION DESTRUCTION t I (No septic system permitted it public sewer is available within 200 feet) Installation will serve: Residence t Commercial Zr Other Number of living units: ____ Number of,bedrooms V Character of soil to a depth of 3 feet: 58tJDY t QW4 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r I PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well !y Foundation LO Property Line } LEACHING LINE ❑ No. & Length'of lines U T otal length/size f �Q , ~ FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ ` SEEPAGE PITS l I Depth Size Number SUMPS L-1 'Distance to nearest: Well Foundation Property Line T DISPOSAL PONDS ❑ Q I hereby certify that I have prepared this application and that the work will be done in accordance with San Joii4din'county ordinances, state laws, and ^� rules and regulations of the San Joaquin Local Health District. - ` Home owner or licensed agents 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 csub-c workman's tin corn iature 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. l i Signed Title: to W, Date: r ' R.ptPARTMENT USE ONLY S -~ Application Accepted by Date ~(P) Area k Pit or Grout Inspection by Data Final 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, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. MFO �//� I ♦.EH 13-24IREV,I/H5i *✓F_v v �� ` �� /� T� ,77 / EH 14-26