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APPLICATION FOR PERMIT . � u SAN JOAQUIN LOCA, HEALTH DISTRICT 1601 E. HAZETON 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. c7`a�_/9 ,p v N Stift w lIGIYlG�� r�. 2 L Jab Address ! }.City Lot Size PM Owner's Name Address fAy , 7_ - t{�1 Contractor AddreSsTO•&x a b7 License N o.A&A9hone 0 TYPE OF WELL/PUMP: NE ELL , WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKOn nef SEWER LINES Wool, DISPOSAL FLD.noPROP. LINE Yl - FOUNDATION OI�G AGRICULTURE WELL nQOC OTHER WELL Y10inG PITS/SUMPS non( non( INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial C7 Open Bottom Ci Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing�G---" 40 Specifications Public /Other Delta Depth of Grout Sealy' Type of Groutt�r I i_Jrfig��,�ayty/ion Approx. Depth I I Eastern Surface Seal Installed by �t ►rte. �l� I vie,Repair( ork Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (tap 501 bwtotli a ,el— Depth Filler Material (Below 50 44 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 2D0 feet.) ^-n Instailation will serve: Residence_ Commercial_ Other 1}yf Number of living units: Number of bedrooms + Character.ofsoil to a depth of 3.feet:. Water table depth _ Y i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments h PKG. TREATMENT PLT.❑ _ Method of Disposal Distance to nearest: Well FoundatiorL Property Line I LEACHING LINE ❑ No. & Length of lines e 'Total length/size FILTER BED- t- - © - Distancetonearest- Well.. Foundation „Property Line SEEPAGE PITS 11 Depth Size —..Number- SUMPS- - ❑ Distance to nearest: Weil Foundation Property Line 'R 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. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature\ certifies the following: "1 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 rota." NL`l-' The al c t ust call for re r ctions. Complete drawing on reverse side. �jSigned X Title: F Date: I F. DEPARTMENT USE ONLY Application Accepted by Date Area / i Pit or Grout Inspection by Date 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, Stk., CA 952111 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EHtiN(REV .i/n51 EN 14-29 l �O �1 I