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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (200) 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health� trjp� /io�w Job Address 7 City Lot Size PM Owner's Name _ � �� n l M,5V14t& Address Phone Contractor.__&A�, 114P Address / License No.a:i _ Phone e TYPE OF WELL/PUMP: NEW WELL .❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION•❑-- - SYSTEM REPAIR ❑ OTHER 0-- DISTANCE --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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 6 1 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by { Repair Work Done Cl Type of Pump i H.P. State Work Done 0 R Well Destruction ❑ Well Diameter Sea6g Material (top 50') j Depth '}Filler Material (Below 501. TYPE OF SEPTIC WORK: NEW INSTALTION V REPAIR/ADDITION ❑ DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet.) a Installation will serve: Re 'dence Commercial_ Other—,e - Number of living units: Number of bedrooms' `. Character of soil to a depth of 3 feet:, Water table depth LA r v .L SEPTIC TANK ❑ Type/Mfg Q �. i"nfl LJf�1�i�Capacity �Ln A ONo. Compartments (� PKG. TREATMENT PLT. ❑ °�► �� t" t Method of Disposal Distance to nearest: Well �Fouhdation Property Line LEACHING,LINE s No. & Length of lines 4 �� _ Total length/size FILTER BED ❑ `Distance to nearest: Well Foundations Property Line SEEPAGE PITS ❑ De th Size Number SUMPS O Distance to nearest: Well Foundation Property Line' ' 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. I 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 taws of California.". The applicant must call for all r uir d inspections. Complete drawing on rev a side. r Signed X ��/eo I Title: Date' �1 FOR DEPARTMENT USE ONLY { Application Accepted by F Data 0- Area r Pit or Grout Inspection by Date Final inspecti n by Date �or Additional Comments: 54 �� / —#Au po.0-h [ ❑ Stk 4W6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 � S � f�i h Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bbx 2009, St ., CA A95201 f r^�I FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO, + EH 1 -241REV.7/65] �` �0 f L 8 + EH 144-29 �"l r