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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT - 1.601 E. HAZEL i ON AVE., STOCKTON, CA 'Telephone (209) 466-6781 �a PERMIT EXPIRES�I 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 �� City p Lot Size PM Owner's Name - -1 _ �� •�+<��-Address.— t / I Cont actor; G �/.�/ � Address License No�3 C��= Phone TYPE OF WELL/PUMP: I NEW WELL'❑-�,, yWELL REPLACEMENT ❑ DESTRUCTION, ❑ t PUMP INSTALLATION ❑ j SYSTEM REPAIR El OTHERj❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. ,DISP-OSAL.FLD.---_._--- PROP—LINE,-- �� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of Casing Specifications ❑ Public # El Other "° 7-pelta Depth of Grout Seal Type of Grout 1 ❑ Irrigation L___�4pprox. Depth ❑ Eastern Surface Seal Installed by f ' Repair Work Done ❑ Type�of Pump H,P. State Work Done Well'Destruction ❑ Well Diameter "f Sealing Material (top 501 7 } Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION INo septic system permitted if public sewer is 1 ! available within 200 feet.( (�t Installation will serve: Residence_ Comrrlercial Other -� -r Number of living units: Number of bedroom_ s ^" Character of soto a depth of 3 feet: - - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ li # � f Method of Disposal d Distance to neFarest:_R_WeIL =-Foundation Property Line i LEACHING LINE O❑'No-&'Length of lines Total length/size FILTER BED � {Dista ce-to nearest: Well Foundation 'Property Line SEEPAGE PITS I ❑ Depth Size Number f SUMPS E Cl Distance to nearest: Well Foundation - —Property Property Line•" i DISPOSAL PONDS ❑ �° I I hereby certify that! 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 Joaquin Local Health District. Home owner or licensed agent's-isignature 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 manne`r 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 Califar ' The applicant r t II far all required inspections. Complete drawing on reverse side.` Signed X Title: Date: F DEPARTMENT USE ONLY 1 1 Application Ac epted by AAfw5 . '11P20sMCXt6A6t Date___45mv-4 Area Pit or Grout Inspection by �' Date Final Inspection by Date Additional Comments: .Q + 0 ❑ 5tk 466 6281 LJ Lodi,;1369-3621 ❑ Manteca 823-7104 DL ,Tracy 835-6385 Ae Applicant- Return all copies to:;Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK \` INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24{REV. EH 14-28 • .gip, _ . � _.�_ - � - - - - .i