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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Pit), 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. rte_ -]� � -hdax� Job Address t G �/ 1LJ �+ 1 City J Lot Size PM Owner's Name CbT� e4. Addressff . i , Phone hrila�L fit,. Contractor �i�i�T'4 'L -�Dy 1 Address 0/Y4ii1So p -.. License No. Phone /6a TYPE OF WELL/PUMP: NEW WELL ❑ WELL ftEPLACEME T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:-of Well Excavation Dia. of Well Casing J 0 Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [I Public �r i] Other,,•;,�° �-� 0 Delta Depth of Grout Seal ""'"`'"'�I Type of Grout I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ,❑_Type_of Pump **H.P. {' State Work Done ..�..� - - _ _ Well Destruction `© Well Diameter Sealing Material (top 50') n z Depth - filler Material4,Below- 50'1,.. TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION l ) .DESTRUCTION I 1 INo septic system permitted if public sewer is # �/ ' available within 200 feet.). Installation will serve: Residence'1- Commercial.. r Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fleet:f Water table depth 1 SEPTIC TANK r—t--O Type/Mfg' Capacity—.,—No..Compartments PKG. TREATMENT PLT. ❑ Method of Disposal E Distance t nearest: Well Foundation Property.Lihe LEACHING LINE ❑ No. & Length of lines - Total length/size p FILTER SED ❑ Distance to-nearest:- Well Foundation Property Line SEEPAGE PITS (SII Depth /2-1_ Size' Number Z ^ S J'1' SUMPS Distance to nearest: Well Foundation Property Line � DISPOSAL PONDS CII �< } 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 D�iltrict. f 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." r 1 I The applicant must call for all required ins � r q inspections. Complete drawing on reverse side. Signed X � Title: Date: 73 • ��!��j(�R DEPARTMENT USE ONLY . •A-. ... ; Application Accepted by �Da Date Area Pit or Grout Inspection by Date Final Inspection by te ' Additional Comments: 4?19, s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ,823-7104 ❑ Tracy 5-6385 i 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 4 . � _ _INFO CASH RECEIVED BY DATE PERMIT-NO. + (REV.11951 EH 14-26 - - -